Loneliness, Living Alone, and All-Cause Mortality: The Role of Emotional and Social Loneliness in the Elderly During 19 Years of Follow-Up

Abstract

Objective: To examine the predictive value of social and emotional loneliness for all-cause mortality in the oldest-old who do, and do not live alone and to test whether these varied by functional status and personality.
Methods: Participants were 413 older adults from the Berlin Aging Study (M ± SD = 84.53 ± 8.61 years of age) who either lived alone (n = 253) or did not live alone (n = 160). Significance values for hazard ratios are reported having adjusted for age, sex, education, income, marital status, depressive illness, and both social and emotional loneliness.
Results: While social loneliness was not associated with mortality in those living alone, emotional loneliness was; with each 1 SD increase in emotional loneliness there was a 18.6% increased risk of all-cause mortality in the fully adjusted model (HR = 1.186; p = 0.029). No associations emerged for social or emotional loneliness among those not living alone. Examinations of potential moderators revealed that with each 1 SD increase in functional status, the risk associated with emotional loneliness for all-cause mortality increased by 17.9% (HRinteraction= 1.179; p = 0.005) in those living alone. No interaction between personality traits with loneliness emerged.
Conclusions: Emotional loneliness is associated with an increased risk of all-cause mortality in older aged adults who live alone. Functional status was identified as one potential pathway accounting for the adverse consequences of loneliness. Emotional loneliness which can arise out of the loss or absence of a close emotional attachment figure appears to be the toxic component of loneliness.

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Loneliness, Living Alone, and All-Cause Mortality: The
Role of Emotional and Social Loneliness in the Elderly
During 19 Years of Follow-Up
Páraic S. O'Súilleabháin, PhD, Stephen Gallagher, PhD, and Andrew Steptoe, PhD
ABSTRACT
Objective: The aims of the study were to examine the predictive value of social and emotional loneliness for all-cause mortality in the
oldest-old who do and do not live alone and to test whether these varied by functional status and personality.
Methods: Participants were 413 older adults from the Berlin Aging Study (M [SD] = 84.53 [8.61] years of age) who either lived alone
(n= 253) or did not live alone (n= 160). Significance values for hazard ratios are reported having adjusted for age, sex, education, income,
marital status, depressive illness, and both social and emotional loneliness.
Results: Although social loneliness was not associated with mortality in those living alone, emotional loneliness was; with each 1 SD in-
crease in emotional loneliness, there was an 18.6% increased risk of all-cause mortality in the fully adjusted model (HR = 1.186, p= .029).
No associations emerged for social or emotional loneliness among those not living alone. Examinations of potential moderators revealed
that with each 1 SD increase in functional status, the risk associated with emotional loneliness for all-cause mortality increased by 17.9%
(hazard ratio
interaction
=1.179,p= .005) in those living alone. No interaction between personality traits with loneliness emerged.
Conclusions: Emotional loneliness is associated with an increased risk of all-cause mortality in older adults who live alone. Functional
status was identified as one potential pathway accounting for the adverse consequences of loneliness. Emotional loneliness that can arise
out of the loss or absence of a close emotional attachment figure seems to be the toxic component of loneliness.
Key words: emotional loneliness, functional status, living alone, loneliness, mortality, social loneliness.
INTRODUCTION
Loneliness is associated with an individual's risk of morbidity
and mortality (1–4). Other research has found that those who
are lonely have higher rates of depression, lower quality of life
(5,6), an increased vulnerability for coronary heart disease (7),
and display atypical cardiovascular reactions to stress (8). Al-
though these studies have treated loneliness as a unidimensional
construct, Weiss (9) in his seminal work suggested that loneliness
has social and emotional dimensions. Recent studies have found
emotional loneliness to be more common than social loneliness
(10) and to be more damaging for health (11). Importantly, the re-
search on loneliness has not disentangled the effects of emotional
and social loneliness for mortality.
According to Weiss (9), emotional loneliness arises out of the
loss or absence of a close emotional attachment figure, whereas so-
cial loneliness arises out of the absence of an engaging social net-
work that is a wider circle of friends and acquaintances that can
provide a sense of belonging, of companionship, and of being a
member of a community (9). Moreover, emotional loneliness he
argued results in feelings of aloneness, anxiety, hypervigilance,
high sensitivity to minimal cues, and feelings of abandonment.
In contrast, he suggested that social loneliness would be associated
with boredom, depression, and aimlessness. Furthermore, recent
studies have found that both social and emotional dimensions are
predicted by different psychosocial and demographic factors
(10,11). Factor analytic studies also indicate that measurement
models, which distinguish between these dimensions of loneli-
ness, are superior to unidimensional models, and that social and
emotional loneliness are only moderately correlated (12). Thus,
given these insights and the fact that loneliness is considered a
public health concern (13) further research is clearly warranted.
The overall aim of the present study was to examine the associa-
tions between social and emotional loneliness and all-cause mortality.
Given living alone in older age has been repeatedly implicated as a
risk factor for premature mortality (14,15), we examined effects
From the School of Psychology (O'Súilleabháin), National University of Ireland Galway; Department of Psychology (O'Súilleabháin, Gallagher), Health Re-
search Institute, University of Limerick, Ireland; and Department of Behavioural Science and Health (Steptoe), University College London, United Kingdom.
Address correspondence to Páraic S. O'Súilleabháin, PhD, School of Psychology, National University of Ireland, Galway, University Road, Galway,
Ireland. E-mail: paraic.osuilleabhain@nuigalway.ie
P.S.O. is currently moving institution and will soon be located at the Department of Psychology, University of Limerick, Ireland.
Received for publication November 19, 2018; revision received March 19, 2019.
DOI: 10.1097/PSY.0000000000000710
Copyright © 2019 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Psychosomatic Society. This is an open-access
article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible
to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission
from the journal.
BASE = Berlin Aging Study, CI = confidence intervals, HR =hazard
ratio
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Psychosomatic Medicine, V 81 •521-526 521 July/August 2019

across individuals who do and do not live alone. In addition, we
sought to examine functional status as a possible moderator of effects,
given its relevance as a crucial marker of health in old age, in addition
to being implicated in loneliness (16,17). Furthermore, personality
traits have been repeatedly associated with loneliness (18) and
health processes and mortality (16,19,20), and as such, it was of
importance to determine whether they may act as a further poten-
tial moderator in the association between loneliness and mortality.
METHODS
Participants
Berlin Aging Study (BASE) begun between 1990 and 1993 and is a multi-
disciplinary investigation of older adults (21,22). Participants recruited in
the BASE were sourced using an obligatory population registry for the entire
city of Berlin. The present sample comprised 413 participants (M (SD) =
84.53 (8.61) years of age) differentiated by living status; those who either lived
alone (n= 253,M (SD) = 85.19 (8.51) yearsof age, range = 70–103 years)
or did not live alone at baseline (n= 160, M (SD) = 83.49 (8.68) years of
age, range = 70–101 years).
Measures
Mortality
Status of mortality was defined as the number of days between the initial
contact at baseline (between 1990 and 1993) and date of death. The final
available update pertaining to the mortality status of participants was in
July 2009. This study sample across follow-up consists of 385 deaths,
and 28 reported as alive in their final update. The study comprised 235 deaths
and 18 reported as alive in those living alone (M (SD) = 2595.53 (1991.04) days,
range = 176–7012 days) and 150 deaths and 10 reported as alive in those not
living alone (M (SD) = 2486.49 (1937.96) days, range = 118–7012 days).
Covariates
The following variables were included as covariates: age; sex (male, fe-
male); education (elementary school, no apprenticeship; elementary school,
apprenticeship; secondary school certificate, apprenticeship); income (de-
fined as the net household income weighted by the number of people shar-
ing the household); marital status (married, widowed, divorced, single);
and depressive illness (based on diagnosis in DSM-III-R into three catego-
ries [no depressive disorder, questionable depressive disorder, or depressive
disorder]). Recent losses (defined as the total number of losses of very close
individuals that the participant deemed as having occurred recently) was
also examined. These variables were selected for the present study given
they are repeatedly implicated in both health and mortality (23–26).
Loneliness
To assess loneliness, eight items were selected from the revised University
of California, Los Angeles (UCLA) Loneliness Scale (27). The scale cap-
tures both social (comprising 4 items; e.g., “I feel part of a group of
friends”) and emotional (comprising 4 items; “I feel isolated”) loneliness.
Items are scored on a five-point Likert scale ranging from 1 “does not apply
to me at all”to 5 “applies very well to me.”Higher scores on eachscale rep-
resents greater feelings of loneliness.A complete list of original scale items,
translations which were made for BASE, and correlations are available in
Table 1. For cross-instrument comparability and ease of interpretation,
scores for loneliness as a unidimensional measure, and both social and
emotional loneliness dimensions wereconverted to standard deviation units
(M (SD) = 0 (1)). Medium to small correlation coefficients were observed
between social and emotional loneliness; in the complete sample
r= .32, in those living alone r= .35, and those not living alone
r= .24. These coefficients are consistent with the range seen in existing
research with older individuals (28). A linear structural relations analy-
sis of BASE data supports the use of both social and emotional loneliness
factors (29). Cronbach's αwere .74 (loneliness), .68 (social loneliness), and
.73 (emotional loneliness).
Functional Status
A modified version of the Katz Index of Activities of Daily Living was
used to measure functional status (30). Participants indicated whether they
need personal assistance with dressing, bathing, toileting, transferring, and
eating (e.g., toileting example: “goingtothetoilet”). Total scores for the
Katz Index represented a range from 0 (completely dependent on help) to
5 (completely independent). A high Cronbach's α(0.87) was observed.
Personality
Neuroticism, extraversion, and openness to experience were measured
using items from the NEO Personality Inventory (31). To measure each
trait, six items were used, which were scored on a five-point Likert scale
which ranged from “does not apply to me at all”to “applies very well to
me.”The following measures of internal reliability consistency were ob-
served (Cronbach's α; neuroticism = 0.75, extraversion = 0.65, openness
to experience = 0.55).
TABL E 1. Correlation Matrix of Loneliness Items, Including Translations
OriginalItems GermanTranslation Dimension1234567
[1] I do not feel alone Ich fühle mich allein
a
Emotional
[2] I lack companionship Ich habe wenig Gesellschaft Emotional .410**
[3] There are people I feel close to Es gibt Menschen, die mir nahe stehen Social .129** .140**
[4] I feel isolated Ich fühle mich isoliert Emotional .483** .406** .186**
[5] There are people I can turn to Es gibt Personen, an die ich mich
vertrauensvoll wenden kann
Social .163** .127** .364** .174**
[6] I feel left out Ich fühle mich ausgeschlossen Emotional .321** .342** .262** .531** .209**
[7] I feel part of a group of friends Ich fühle mich einem
Bekanntenkreis zugehörig
Social .123* .264** .349** .176** .336** .149**
[8] There are people I can talk to Es gibt Menschen, mit denen ich
offen sprechen kann
Social .172** .129** .326** .239** .555** .241** .271**
a
Double negatives were avoided in the translation.
*p<.05.
** p<.01.
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Statistical Analyses
Statistical analyses were conducted using PASW Statistics 24.0 (SPSS Inc,
Chicago, IL) and R (32). To consider time-to-event while including those
reported asalive (censored), the Cox Proportional HazardsModel was used
to estimate the risk of death. Models examining the association between the
unidimensional measure of loneliness are reported both unadjusted and
adjusted for covariates. Following this, models examining the associa-
tion between both emotional and social loneliness were similarly re-
ported. Variables in the model are entered simultaneously with effects
and significance levels estimated after full adjustment. For categorical
variables, the method of contrast was set to simple, which allows each cate-
gory of the predictor variable to be compared with the reference category,
which was set to the first category in each instance. Furthermore, significant
effects were illustrated by dividing participants into tertiles of loneliness.
Schoenfeld Residual Analysis revealed the assumption of proportional
hazards was not violated. Hazard ratios (HRs) and 95% confidence inter-
vals (CIs) were reported for Cox Proportional Hazards analyses.
RESULTS
First, we examined descriptive statistics of the present sample,
which revealed several significant differences within the present
sample (Table 2). Particularly noteworthy are the observed signif-
icant differences in sex and marital status observed between those
who do and do not live alone. We then examined the unidimen-
sional measurement of loneliness (M (SD) = 2.13 (0.61)) as a sig-
nificant predictor of all-cause mortality. Loneliness emerged as a
significant predictor of all-cause mortality within the unadjusted
model (HR = 1.176, p< .001, 95% CI = 1.074–1.289). After adjust-
ment for all covariates the observed effect was no longer significant
(HR = 1.07, p= .22). Given the previously outlined importance of
considering living status, we also introduced an interaction be-
tween loneliness and living status, which did not emerge as signif-
icant (HR
interaction
= 0.85, p=.16).
Wethen repeated this procedure with both social and emotional
dimensions of loneliness. Within the unadjusted models, social
loneliness did not emerge as a significant predictor of all-cause
mortality (HR = 1.10, p= .057). Emotional loneliness did emerge
as a significant predictor (HR = 1.214, p< .001, 95%
CI = 1.105–1.333). Following this, we examined both social and
emotional loneliness effects within the fully adjusted model. Both
social (HR = 1.01, p= .81) and emotional (HR = 1.06, p=.29)
loneliness were not observed as significant after adjustment
for all covariates. We then introduced an interaction term with
living status for both dimensions. The interaction between emotional
loneliness and living status emerged as significant (HR
interaction
=0.804,
TABL E 2. Descriptive Statistics of the Present Sample
Living Alone (n= 253) Not Living Alone (n=160)
M/nSD/% M/nSD/% ttest/χ
2
Age, y 85.19 8.51 83.49 8.68 0.051
Sex <0.001
Male 98 38.7% 125 78.1%
Female 155 61.3% 35 21.9%
Education 0.111
Elementary school, no apprenticeship 77 30.4% 36 22.5%
Elementary school, apprenticeship 123 48.6% 79 49.4%
Secondary school certificate, apprenticeship 53 20.9% 45 28.1%
Income (Deutsche mark)* 2067.77 960.66 1824.12 873.69 0.010
Depressive illness 0.007
No depressive disorder 132 52.2% 108 67.5%
Questionable depressive disorder 103 40.7% 42 26.3%
Depressive disorder 18 7.1% 10 6.3%
Marital status <0.001
Married 8 3.2% 122 76.3%
Widowed 191 75.5% 35 21.9%
Divorced 26 10.3% 0 0%
Single 28 11.1% 3 1.9%
Recent losses 0.91 1.20 0.75 1.21 0.182
Functional status 4.55 1.15 4.38 1.32 0.147
Neuroticism 2.38 0.79 2.22 0.71 0.035
Extraversion 3.37 0.56 3.35 0.61 0.735
Openness to experience 3.13 0.59 2.97 0.55 0.007
Loneliness (unidimensional)* 2.23 0.64 1.96 0.53 <0.001
Emotional loneliness* 2.42 0.87 1.99 0.70 <0.001
Social loneliness* 2.05 0.70 1.95 0.65 0.133
* Represents raw values before conversion to standard deviation units.
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p= .043,95% CI = 0.650–0.994), whereas social loneliness did not
(HR
interaction
=0.95,p=.64).
Emotional Loneliness and Living Status
To further examine the potential effects of emotional loneliness
and living status, we examined emotional loneliness effects in
persons who do and do not live alone. Within the unadjusted
model, emotional loneliness emerged as a significant predictor
of all-cause mortality in those living alone (HR = 1.316,
p< .001, 95% CI = 1.160–1.493), but not in participants who
did not (HR = 1.09, p= .25). In the fully adjusted model for
those living alone, emotional loneliness remained significant
after adjustment (HR = 1.186, p= .029, 95% CI = 1.017–1.383).
Each 1 SD increase in emotional loneliness was associated with
an 18.6% increased risk in all-cause mortality (Figure 1). The
other independent predictors in the model were; sex
(HR = 0.662, p= .007, 95% CI = 0.490–0.892), age
(HR = 1.114, p< .001, 95% CI = 1.091–1.138), education
(comparison of elementary school, no apprenticeship, and both
elementary school, apprenticeship [HR = 1.17, p= .31], and
secondary school certificate, apprenticeship [HR = 1.651,
p= .018, 95% CI = 1.190–2.501]), marital status (all
p's > .29), income (p= .088), depressive illness (all p's > .45),
and social loneliness (HR = 0.99, p= .94). The observation that
many of those living alone were widowed raised the possibility
that bereavement may account for observed effects with emo-
tional loneliness (Table 2). As such, we included the total num-
ber of recent losses of close persons within the adjusted model.
The inclusion of recent losses within the model did not alter the
effects of emotional loneliness (HR = 1.194, p= .024, 95%
CI = 1.024–1.394).
We also conducted a moderation analyses to determine poten-
tial pathways of the effect observed for emotional loneliness in
those living alone. First, functional status and its interaction with
emotional loneliness were entered within the fully adjusted model.
Functional status significantly predicted mortality (HR = 0.766,
p< .001, 95% CI = 0.685–0.865), with lower mortality among par-
ticipants with better functional status. A significant effect also
emerged for the interaction between emotional loneliness and func-
tional status (HR
interaction
= 1.179, p= .005, 95% CI = 1.051–1.323).
Thus, for each increase in independence in functional status, the ef-
fect rate of loneliness on all-cause mortality increased by 17.9%. For
personality traits, all analyses revealed no significant interaction
effect between neuroticism, extraversion, and openness to experi-
ence, and emotional loneliness (all p's > .11).
DISCUSSION
Although other studies have suggested emotional loneliness to be
more damaging for health than social loneliness, the present study
provides new evidence showing that emotional loneliness is asso-
ciated with mortality in very old adults who live alone. More spe-
cifically, in a sample of older adults followed for 19 years, higher
emotional loneliness was found to significantly predict an in-
creased risk of all-cause mortality. This effect remained after the
adjustment for several confounds, including clinically assessed de-
pression.No significant effectswere observedfor social loneliness
in those living alone. Similarly, no significant loneliness effects
were observed for individuals who did not live alone. The previ-
ously observed significant effects for loneliness as a unidimen-
sional measure did not remain significant after adjustment for all
covariates.
A growing literature base is indicating the relevance of loneli-
ness on health into old age. Here, however, we extend on this to
show that emotional loneliness, which is often associated with
feelings of abandonment and anxiety, to be the toxic component
of loneliness. Moreover, it has identified those at greatest risk,
older adults who live alone and experience this sense of emotional
abandonment, whereas this risk was not evident in those older
adults living with someone and had the same experiences. This
could well be the result of living alone being primarily the result
of bereavement. Although the supplementary examination of
recent losses did not alter the effect, further research needs to
FIGURE 1. Kaplan-Meier plot of those living alone illustrating the proportion of persons surviving by tertiles of emotional loneliness.
Note: The analyses examined days to death, years are represented here for clarity. + indicates censored points.
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examine this potential pathway in detail. Furthermore, a full ex-
amination of possible biobehavioral pathways in the associations
between emotional loneliness, living alone, and mortality is re-
quired. Though speculative, the mechanisms implicated within
existing literature on loneliness more broadly (e.g., increased hy-
pothalamic adrenocortical functioning, altered gene expression,
increased inflammation, and poor sleep, for review see (33) and
(34)) may be similar.
Increases in emotional loneliness resulted in an increase of the
effect rate of functional status on mortality. Functional status is a
crucial marker of health in old age, and its decline represents health
deterioration. Existing research has linked functional status and
loneliness (35). This study provides new evidence that functional
status may provide a pathway in the association between emo-
tional loneliness and mortality in persons who live alone. Further-
more, despite personality traits accounting for an individual's
tendency to exhibit consistent thoughts, emotions, and behaviors
for long periods, and being repeatedly associated with loneliness,
they did not emerge as significant moderators of emotional loneli-
ness and mortality.
STRENGTHS AND LIMITATIONS
The present study examined a heterogeneous and locally represen-
tative sample followed for a long period. This study also used sev-
eral data forms known to predict all-cause mortality. The study
used theoretically appropriate and methodologically robust covar-
iates. However, limitations must be duly noted. This study is of the
oldest old, and as such, it is unclear how these effects generalize to
younger cohorts. It must also be noted that the translated items for
the UCLA loneliness scale used within BASE may also be open to
cultural influences in its interpretation. Future research must also
consider the generalizability of these findings in the context of cul-
tural differences across countries. Cultural differences between in-
dividualistic and collectivistic societies across Europe in the
experience of loneliness have been documented (36). Furthermore,
although average levels of loneliness within the present sample are
below the midpoint of the scale with the complete range of ratings
used, it is difficult to compare loneliness levels across studies
given a subset of items from the UCLA loneliness scale were used
during data collection. In addition, the variable included to address
the possibility of bereavement may not capture the loss of a close
individual beyond what an individual may consider recent. As such,
it is imperative that future research clearly examines the potential for
a bereavement pathway within the loneliness and mortality context.
Itwouldhavebeenbeneficialtothestudyifinformationpertaining
to status of living alone was available repeatedly for the follow-up
period. This would have provided a clearer separation of both
groups across the entire follow-up period. In addition, future re-
search should consider the associations between loneliness and
various illness and disease trajectories and their resulting effect
on mortality, particularly in the case of samples consisting of the
oldest old. Although there was no information available about
cause of death in the present sample, future research should exam-
ine potential associations with specific types of mortality.
CONCLUSIONS
This study provides new evidence that emotional loneliness is as-
sociated with all-cause mortality in older adults who were living
alone. Those highest in emotional loneliness were at a greater risk
of premature mortality. Functional status was identified as one po-
tential pathway of effect. Present findings suggest future research
would benefit from the further examination of associations be-
tween emotional loneliness and mortality in older adults who live
alone. The results of this present study would suggest that the emo-
tional component of loneliness seems to be of relevance to mortal-
ity, above social loneliness effects.
We want to thank all the researchers and participants who
were part of the Berlin Aging Study. We are also very grateful
for the assistance of Dr. Julia Delius and Mr. Martin Becker.
Source of Funding and Conflicts of Interest: This article re-
ports on data from the Berlin Aging Study (BASE). This study
was supported by the Max Planck Society, the Free University of
Berlin, the German Federal Ministry for Research and Technology
(1989–1991, 13 TA 011 12 TA 011/A), the German Federal Ministry
for Family, Senior Citizens, Women, and Youth (1992–1998, 314-
1722-102/9 314-1722-102/9a), and the Berlin-Brandenburg Acad-
emy of Sciences' Research Group on Aging and Societal Development
(1994–1999) for BASE. Irish Research Council New Horizons
(REPRO/2016/72). The authors report no conflicts of interest.
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ORIGINAL ARTICLE
Psychosomatic Medicine, V 81 •521-526 526 July/August 2019