Loneliness at the ED

Author: Zohar Lederman, MD, PhD (Rambam Healthcare Campus) // Reviewed by: Alex Koyfman, MD (@EMHighAK) and Brit Long, MD (@long_brit)

“His kids stopped visiting him because of Covid- he last saw them six months ago. They and the grandchildren are the most important thing in the world for him. So he felt lonely, and that’s why he tried to die.”

Prior to Covid, one of the hardest experiences in the ED was discharging patients who refuse to leave. It was hard partially because when Israelis do not get what they want- to be admitted to hospital in this case- they get upset.  But mainly, it was hard because you knew you were not helping patients cope with the problem that actually brought them to the ED- loneliness, the subjective discrepancy between one’s social need and one’s actual social interactions.¹

During Covid, loneliness got worse. We know that from empirical studies,^2-4 and we probably all felt that in our own experiences. The patient mentioned above consumed ten pills of lorazepam in an attempt to kill himself because of loneliness. Luckily he failed; but others have succeeded.

Even though it is hard sometimes to disentangle loneliness from social isolation and depression, loneliness is known to be common globally, with pre-Covid numbers being around 20% depending on the country and age groups. Loneliness is also known to be a major risk factor for health, on a level comparable to diabetes, high blood pressure and smoking. Loneliness can also lead to depression.^{5, 6}

So loneliness is ubiquitous and deadly. But what is it to emergency medicine docs?

A 2021 report by the US National Academies of Sciences, Engineering, and Medicine emphasized the role of healthcare providers in mitigating the adverse effects of loneliness and social isolation. ⁷ The report further states that “a single interaction with the health care system may represent the only opportunity to identify those individuals who are the most isolated and lonely.”⁷ The report unfortunately focuses on people aged 50 and above because younger people are alleged to be less likely to interact with the healthcare system. ‘Less likely’, however, is not ‘not at all.’

Many of the public healthcare systems nowadays are not functioning the way they should. A lot has been already said about the US.⁸ In many countries, Israel included, folks mostly visit the ED for non-urgent issues, hoping to speed up testing or being dissatisfied with the available primary care. Some of the folks eventually turn to their primary care providers, but some never do. Even when patients do turn to their primary care provider, they often do not receive optimal care.

For some patients then, EM docs may become the first and even the only point of contact with the healthcare system. This creates a professional and ethical responsibility to do our best to prevent and mitigate the negative effects of loneliness.

The National Academies report sets out five goals to enhance the role of healthcare providers:

1. Develop a more robust evidence base for effective assessment, prevention, and intervention strategies for social isolation and loneliness.
2. Translate current research into health care practices in order to reduce the negative health impacts of social isolation and loneliness.
3. Improve awareness of the health and medical impacts of social isolation and loneliness across the health care workforce and among members of the public.
4. Strengthen ongoing education and training related to social isolation and loneliness in older adults for the health care workforce.
5. Strengthen ties between the health care system and community-based networks and resources.

I am in the process of reviewing the literature on loneliness at the ED and potential tools and interventions that EM docs can employ to curb loneliness. But one may confidently conclude that loneliness has not been on the minds of EM docs, at least not in relation to their potential and actual patients. While we know loneliness prevalence in the community in the US and other countries, we know very little about it in ED’s around the world. Similarly, the evidence associating loneliness and ED visits is slim. For instance, in 1999, a group at Lawrence General Hospital in Massachusetts hypothesized that loneliness would cause an increase in ED visits. The authors reasoned that since loneliness increases risk for cardiovascular and other diseases, lonely people would be sicker and would thus visit the ED more often compared those who are not lonely.⁹ To test their hypothesis the authors sampled 164 patients presenting to the ED and administered the UCLA loneliness questionnaire. They also quantified the number of ED visits and outcome of visits. Statistically significant findings included the following:

1. Lonely people were not sicker compared to not-lonely people, i.e. they did not have more chronic morbidities.
2. Loneliness positively correlated with the frequency of ED visits.
3. Loneliness did not correlate with hospital admissions.

Bottom line: Lonely people visited the ED more often but were not sicker.

We then should do much more to understand and measure loneliness in the ED and its effects on ED visits. We should also devise and assess interventions to mitigate loneliness and potentially reduce work loads in ED’s. We should concurrently train ED staff to identify and address loneliness at the ED, thus optimizing care and contributing to public health. For these purposes, strengthening ties with community-based networks should also be sought.

Loneliness seems in a way to be outside of the EM paradigm. We are trained first to save lives, second to provide treatment at the ED, and third to decide whether to admit or discharge. The kind of public health perspective that is felt to be needed to adequately address loneliness thus exceeds our professional purview. Even if that is the case, our ethical responsibility to mitigate loneliness compels us to widen that purview. The same way we should recommend smoking cessation and exercise to our patients, we should also screen them for loneliness, and find evidence-based measures to reduce loneliness and thus increase the wellbeing in our community.

Take-home message: Some of your patients are lonely, and they are, or will be, sick because of that. Screen, treat, and prevent.

References

1. Lederman Z. Loneliness at the emergency department. The American journal of emergency medicine. 2020;38(8):1688.
2. McGinty EE, Presskreischer R, Han H, Barry CL. Psychological Distress and Loneliness Reported by US Adults in 2018 and April 2020. JAMA. 2020;324(1):93-4.
3. van Tilburg TG, Steinmetz S, Stolte E, van der Roest H, de Vries DH. Loneliness and Mental Health During the COVID-19 Pandemic: A Study Among Dutch Older Adults. The Journals of Gerontology: Series B. 2020.
4. Bu F, Steptoe A, Fancourt D. Who is lonely in lockdown? Cross-cohort analyses of predictors of loneliness before and during the COVID-19 pandemic. Public Health. 2020;186:31-4.
5. Valtorta NK, Kanaan M, Gilbody S, Ronzi S, Hanratty B. Loneliness and social isolation as risk factors for coronary heart disease and stroke: systematic review and meta-analysis of longitudinal observational studies. Heart. 2016;102(13):1009.
6. Courtin E, Knapp M. Social isolation, loneliness and health in old age: a scoping review. 2017;25(3):799-812.
7. Social Isolation and Loneliness in Older Adults: Opportunities for the Health Care System. USA: The National Academies of Sciences; 2020.
8. Emanuel EJ. Reinventing American Health Care. New York: Public Affairs; 2014.
9. Geller J, Janson P, McGovern E, Valdini A. Loneliness as a predictor of hospital emergency department use. The Journal of family practice. 1999;48(10):801-4.