Amid the COVID-19 pandemic, two interdisciplinary pan-Canadian research initiatives have illuminated the social isolation and loneliness of seniors who age at home. The National Institute on Ageing at Toronto Metropolitan University and the Canadian Coalition for Seniors' Mental Health are exemplars in how to treat healthcare innovations as opportunities to create a sustainable high-quality healthcare system. Knowledge translation and communication with the public are core to the values and strategy of both organizations. Clinician leaders at these organizations take a holistic approach to understanding and communicating the importance of social isolation and loneliness among seniors.

Introduction

Solitude can offer solace to some and ache to others. It is whether we choose solitude or whether solitude chooses us that can make a profound difference to our health and longevity.

Unwanted isolation and loneliness often progress to problems in mood (depression, irritation and anxiety); memory functions and attention; mobility, immunity and metabolism; and hormone balance. Social isolation can lead to premature death (National Academies of Sciences, Engineering, and Medicine et al. 2020).

Too many of Canada's elderly who value their independence and age in their own homes do not enjoy autonomy over when and how to embrace solitude comfortably while also maintaining the capacity to connect meaningfully with others should they choose to. Loneliness or isolation, often borne in silence, can significantly damage their quality of life (NIA 2022). Amid the COVID-19 pandemic, important, interdisciplinary pan-Canadian research initiatives have thrown a spotlight on the social isolation of much of our elderly population who age at home – and these initiatives provide some promising solutions.

Rising Interest in Aging in the Right Place

When pandemic lockdowns began in Canada in mid-to-late March of 2020, the frequency of Google searches by Canadians for the term “social isolation” spiked like never before. “What does social isolation mean?” and “Do I suffer from social isolation?” were the questions that lonely seniors and those caring for them asked online during the early days of pandemic lockdowns.

Social isolation is a “meta-concept,” and it overlaps with another more every-day word: loneliness. Great literature that has stood the test of time – notably Silas Marner by George Eliot and Frankenstein by Mary Shelley – remain classics today in part because they expose for readers the torment that rides on the coattails of social isolation.

Healthcare has largely ignored sensitive topics such as these. One paper published in 2023 in the New England Journal of Medicine noted that “social isolation and loneliness are rarely listed on death certificates, yet they may have contributed to the excess deaths from all causes observed during the pandemic” (Holt-Lunstad and Perissinotto 2023: 195). Moreover, there exist neither established scales nor clinical protocols in Canada to diagnose and assess the extent to which an elderly person suffers from friendlessness or alienation – nor how to remedy the situation.

My research suggests that while these states of mind have been heavily documented in peer-reviewed literature as contributors to poor health among seniors, especially mental health, they do not enjoy construct validity or construct stability. They are, in other words, slippery concepts. Yet just because a concept has proven hard to measure does not mean we should give up on seeking precision on how to measure and monitor it; measurement is essential to understanding the trajectories of loneliness and social isolation.

Social isolation – a more objective concept than loneliness – has been defined as “a lack in quantity and quality of social contacts,” a psychological state that “involves few social contacts and few social roles, as well as an absence of mutually rewarding relationships” (Keefe et al. 2006: 1). Relatedly, loneliness – more subjective in nature – has been defined as a “distressing feeling that accompanies the perception that one's social needs are not being met by the quantity, or especially the quality, of one's social relationships” (Hawkley and Cacioppo 2010: 218).

The National Institute on Ageing (NIA) (https://www.niageing.ca/) at Toronto Metropolitan University offers an important lens into how one's sense of isolation might be mitigated: through “Ageing in the Right Place,” or “AIRP” (NIA 2023). The NIA defines AIRP on its website as “[t]he process of enabling healthy ageing in the most appropriate setting based on an older person's personal preferences, circumstances and care needs” (NIA 2023).

How, then, can we promote AIRP in Canada and offer a salve to loneliness and social isolation among those stay-at-home seniors in search of help?

To answer this question, consider first that loneliness is subjective, always seen through the eyes of the beholder. Scientific inquiry into perceived loneliness has been described as “a chronic distress without redeeming features” (Cacioppo and Hawkley 2009: 447). Humans fail to thrive “whether they live solitary lives or they simply perceive they live in relative isolation” (Cacioppo and Hawkley 2009: 447). We may behold a person as living in the centre of a loving family, but their perception may differ. We may offer various solutions that they repeatedly turn down, but we need to respect the choices individuals make.

Recent Canadian Innovations for Aging in the Right Place

In seeking to highlight Canadian innovations for AIRP, I chose to focus on new findings that are potentially generalizable to a substantial number of private Canadian dwellings. I am not highlighting the many opportunities that might emerge from “smart technology” solutions because these ideas, though empowering to some, are not presently accessible to a broad range of elderly Canadians. I, therefore, sought out replicable, high return-on-investment (ROI) solutions. I restricted my findings to research focusing on Canadian experiences, published during 2021–2023.

Literature reviews can be limiting in any nascent field – they can delude us into thinking that we have happened on an innovative finding only because it is frequently cited or published in a high-impact journal. On stigmatized topics especially, findings about innovation may be stale-dated and no longer relevant.

I turned, therefore, to online discussion forums about social isolation and loneliness among seniors. The findings generating the most engaged discussion about AIRP in Canada during 2021–2023 – which also satisfied all my criteria for high-ROI replicable innovation – were a series of interdisciplinary reports from two organizations and their affiliated researchers: the NIA and the Canadian Coalition for Seniors' Mental Health (CCSMH) (https://www.ccsmh.ca).

Knowledge translation and communication with the public are core to the ethos of both organizations. Clinician leaders at these two organizations – Samir Sinha and David Conn, respectively – take a holistic approach to understanding and communicating the importance of social isolation and loneliness among seniors. David Conn of the CCSMH was propelled into geriatric psychiatry during his medical residency because he wanted to help make sense of the “brain, the mind, and a person's mental health as a whole,” he said. Samir Sinha of the NIA told me that he pursued geriatric care because a mentor had said to him, “geriatrics gives permission to care for the whole patient.”

I consider these interdisciplinary organizations to be exemplars in how to treat healthcare innovations as opportunities to create a sustainable high-quality health system. They neither see seniors' care as a burden nor fret about the “greying tsunami” – a common refrain used to describe the perceived financial toll of the aging baby boomer generation on Canadian taxpayers. Both the NIA and the CCSMH display in their reports and public commentary a healthy and positive view of aging for all persons, no matter where they might be on the continuum of aging or in cognitive or physical impairment.

For example, a January 2023 paper co-authored by Spencer Naylor and Samir Sinha of the NIA recommended that we enlist Canada Post workers to conduct home visits with elderly Canadians to support AIRP (Naylor and Sinha 2023). Canadians trust their postal workers, they found, and postal workers are experienced in how to lend a hand to diverse seniors in need of information, household chores and friendliness. The authors pointed to successful postal service–led community support programs in other jurisdictions, such as Japan's “Watch Over” program (Naylor and Sinha 2023: 5). They observe that:

The workforce and vehicle infrastructure of Canada Post could therefore be ideal resources to incorporate into a broader, national strategy to enable older adults to age in the right place, and could represent a significant opportunity to improve population health, particularly in rural and remote communities across Canada (Naylor and Sinha 2023: 8).

In addition to home visitation, the NIA report by Naylor and Sinha (2023) discusses how Japan's “Watch Over” program offers delivery services and 24-hour access to groceries to seniors living at home. Naylor and Sinha (2023) point to one motivation for the Japanese government's ongoing support of the Watch Over program: to prevent an epidemic of “lonely deaths,” wherein elderly people die alone, and their bodies stay undiscovered for long periods of time.

Amid the COVID-19 pandemic, the NIA and other innovation hubs have been at the forefront of producing research promoting the coordinated delivery of interdisciplinary health services in naturally occurring retirement communities (NORCs). This can ensure the continuity of high-quality care for seniors facing a range of conditions, including social isolation. For technology-enabled innovations for seniors in these communities, AMS Healthcare (https://www.ams-inc.on.ca) and University Health Network's OpenLab (https://uhnopenlab.ca/) are leading the design of new digital products to support connectivity for NORC residents. The NIA's NORC-related research shares a common theme with its re-imagination of postal delivery service: first, treat seniors where they are, and, second, think about an expansive definition of service providers – a Canada Post worker, in my view, may have more daily connectivity with stay-at-home elders than most mid-career clinicians.

Empathy and observation of the current state of how seniors experience loneliness in different communities and in different ways are the common threads between the work of the NIA and that of the CCSMH. At the CCSMH, the Social Isolation and Loneliness Project has embarked on the formulation of clinical guidelines for these conditions (CCSMH n.d.). This is an ambitious project, a two-year initiative funded by an anonymous private foundation, and it seeks to empower family physicians and other primary care providers who might be the only point of social contact for many seniors across Canada. Ultimately, the CCSMH aims to disseminate best practice guidelines and toolkits, as well as raise awareness about how best to diagnose and treat older people aging at home. Among other benefits, clinical guidelines hold out the promise of improved quality and consistency of care, improved outcomes, greater healthcare equity across the seniors' population and patient empowerment (i.e., control over what happens to them).

The CCSMH team has identified myriad scales and tools for the screening and assessment of social isolation, loneliness and/or social supports – some of which have been validated in older adults, including the Berkman–Syme Social Network Index (SNI) (Berkman and Breslow 1983). At present, these screening tools are primarily used by researchers and not in clinical practice settings.

Three of the 11 questions in the SNI struck me as pertinent not only when measuring social isolation and loneliness among the stay-at-home elderly but also when assessing a high-quality healthcare system – through the perspective of all patients:

• Is there someone available whom you can count on to listen to you when you need to talk?
• Is there someone available to give you good advice about a problem?
• Can you count on anyone to provide you with emotional support (talking over problems or helping you make a difficult decision)?

To help older Canadians living at home who are unable to answer “yes” to all these questions, we need new innovations in AIRP.

Listening to Our Elders

Long hours alone with one's thoughts is hard to bear for many at an older age. To paraphrase the poet Philip Larkin in “Vers de Société,” it is not parties or social gatherings that lonely aging people generally want. The majority want visits from someone who will distract them from fears of the future (Larkin 2001). The NIA and the CCSMH are, therefore, models to emulate; with passion, empathy, collaboration and optimism, they are leading the way to convert the distressing isolation so many elders feel with innovations that support empathic companionship.

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