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COVID-19-Related Loneliness and Psychiatric Symptoms Among Older Adults: The Buffering Role of Subjective Age

      Highlights

      • Does subjective age moderate the relationship between loneliness and psychiatric symptoms among older adults during the COVID-19 pandemic?
      • Loneliness due to the COVID-19 pandemic was weakly associated with psychiatric symptoms among older adults who felt younger than their age. Older adults who had an older subjective age were more susceptible to the adverse concomitants of loneliness.
      • Subjective age may help identify older adults who are most at risk to suffer from loneliness during the COVID-19 pandemic, and interventions can aim at ameliorating both loneliness and older subjective age.

      ABSTRACT

      Objective

      The study examined whether subjective age moderated the relationship between loneliness due to the COVID-19 pandemic and psychiatric symptoms.

      Methods

      A convenience sample of older adult Israelis (N = 277, mean age = 69.58 ± 6.72) completed web-based questionnaires comprising loneliness, anxiety, depressive, and peritraumatic distress symptoms. They also reported how old they felt.

      Results

      The positive relationship between loneliness due to the COVID-19 pandemic and psychiatric symptoms was weak among those who felt younger than their age while this very same relationship was robust among those feeling older.

      Conclusions

      Young subjective age may weaken the loneliness-symptom association among older adults during the COVID-19 pandemic. Older adults holding an older age identity are more susceptible to the adverse effects of loneliness. Although preliminary, the findings may inform screening and interventions. Subjective age may help identify those at high risk in suffering from loneliness, and suggest interventions aimed at ameliorating both loneliness and older subjective ages.

      Key Words

      OBJECTIVE

      In response to the coronavirus disease 2019 (COVID-19) pandemic, a global policy of social distancing was initiated. Although circumstances necessitate such extreme measures, this social isolation places individuals at risk for adverse health effects.
      • Brooks SK
      • Webster RK
      • Smith LE
      • et al.
      The psychological impact of quarantine and how to reduce it: rapid review of the evidence.
      Older adults at greater risk for COVID-19 health complications will likely remain in strict self-isolation longer than other age groups; therefore, the effects of isolation and ensuing loneliness may be especially severe for them.
      • Vahia IV
      • Blazer DG
      • Smith GS
      • et al.
      COVID-19, mental health and aging: a need for new knowledge to bridge science and service.
      Loneliness reflects subjective distress resulting from a discrepancy between desired and perceived social relationships.
      • Jeste DV
      • Lee EE
      • Cacioppo S
      Battling the modern behavioral epidemic of loneliness: suggestions for research and interventions.
      Unfortunately, loneliness causes a host of poor outcomes such as depression, anxiety, physical morbidity, and mortality.
      • Jeste DV
      • Lee EE
      • Cacioppo S
      Battling the modern behavioral epidemic of loneliness: suggestions for research and interventions.
      These findings stress the need to rapidly assess the concomitants of loneliness among older adults during the COVID-19 pandemic.
      Older adults considerably vary in health status and coping mechanisms; a critical goal is to map risk assessment: who is more susceptible and who is relatively resilient to effects of loneliness. While prior works focused on chronological age as a modifier of the effects of loneliness,
      • Jeste DV
      • Lee EE
      • Cacioppo S
      Battling the modern behavioral epidemic of loneliness: suggestions for research and interventions.
      it is possible that the age at which individuals perceive themselves to be, or their subjective age, would be a more potent moderator. Evidence shows that relative to those feeling younger, older adults with an older subjective age were more prone to a myriad of adverse health outcomes including physical impairment and higher mortality risk.
      • Stephan Y
      • Sutin AR
      • Terracciano A
      Determinants and implications of subjective age across adulthood and old age.
      Moreover, older adults feeling older were more susceptible to the effects of stress.
      • Stephan Y
      • Sutin AR
      • Terracciano A
      Determinants and implications of subjective age across adulthood and old age.
      Subjective age can potentially moderate effects of loneliness on psychiatric symptoms as an older age identity may reflect the internalization of negative age stereotypes.
      • Stephan Y
      • Sutin AR
      • Terracciano A
      Determinants and implications of subjective age across adulthood and old age.
      Accordingly, feeling old indicates viewing oneself as weak and viewing loneliness as an unavoidable part of aging, thereby inhibiting coping behaviors when in self-isolation. Second, negative health conditions accompanying old subjective age, such as inflammation and health-risk behaviors,
      • Stephan Y
      • Sutin AR
      • Terracciano A
      Determinants and implications of subjective age across adulthood and old age.
      can aggravate the noxious effects of loneliness when an old age identity exists.
      We therefore hypothesized that loneliness due to the COVID-19 pandemic would be related to higher levels of psychiatric symptoms (i.e., anxiety, depressive, and peritraumatic distress symptoms) among older adults, especially among those feeling older. The loneliness-symptom association was hypothesized to be weaker as subjective age is younger.

      METHODS

      Participants and Procedure

      Using the Qualtrics web-based platform, we collected data across Israel between March 16 and April 14, 2020. On the last day of data collection, 12,361 Israelis were tested positive for the coronavirus and 123 had died. The sample included 277 older adults (mean age = 69.58 ± 6.72, range 60–92). Most of them were women (n = 191, 69.0%), married or cohabitating (n = 204, 73.6%), with tertiary education (n = 201, 72.8%). Less than half of the sample (n = 115, 42.9%) reported having chronic medical conditions suspected to increase the risk of death due to COVID-19 complications. The majority rated their health as good or very good (n = 178, 64.5%).
      The online questionnaire was disseminated across multiple social media resources and contact lists provided by organizations (e.g., continuing-care retirement communities, institutions hosting educational activities for older adults). All participants provided an informed consent. Ethical approval was received from the institutional review board at the authors’ University.

      Measures

      Participants completed background characteristics, including age, gender, marital status, and education (rated from 1 = without formal education to 6 = formal tertiary education). They noted whether they have chronic medical conditions suspected to increase the risk of death due to COVID-19 complications (i.e., cardiovascular disease, diabetes, chronic respiratory disease, hypertension, and cancer), and rated their health on a scale ranging from 1 (not good at all) to 5 (very good). Exposure to COVID-19 pandemic-related events was the sum score of six events. Behavioral change due to the pandemic was the sum of eleven changed behaviors (details presented in the Supplementary file).
      Participants completed the below measures while being asked to refer directly to feelings and symptoms they experience during the COVID-19 crisis and due to it.
      Subjective age was assessed by a 4-item scale referring to mental, physical, behavioral, and appearance-related aspects of age identity.
      • Kastenbaum R
      • Derbin V
      • Sabatini P
      • et al.
      “The ages of me”: toward personal and interpersonal definitions of functional aging.
      Each aspect was rated on a 5-point scale (1 = feeling much younger than my age to 5 = feeling much older than my age). Ratings were averaged with higher scores reflecting an older age identity. Internal reliability was good (α = 0.82).
      Loneliness was assessed with the 3-item version of the UCLA Loneliness Scale.
      • Hughes ME
      • Waite LJ
      • Hawkley LC
      • et al.
      A short scale for measuring loneliness in large surveys: results from two population-based studies.
      Items were rated on a 5-point scale (1 = not at all to 5 = almost always). Ratings were averaged with higher scores reflecting increased loneliness. Internal reliability was good (α = 0.81)
      Anxiety symptoms were assessed with the 7-item Generalized Anxiety Disorder (GAD-7) scale.
      • Spitzer RL
      • Kroenke K
      • Williams JB
      • et al.
      A brief measure for assessing generalized anxiety disorder: the GAD-7.
      Participants rated their symptoms during the last 2 weeks on a 4-point scale (0 = not at all to 3 = almost every day). Ratings were summed with higher scores reflecting increased anxiety. Internal reliability was good (α = 0.89).
      Depressive symptoms were assessed with the 9-item Patient Health Questionnaire (PHQ-9).
      • Kroenke K
      • Spitzer RL
      • Williams JB
      The PHQ‐9: validity of a brief depression severity measure.
      Participants rated their symptoms in the last 2 weeks on a 4-point scale (0 = not at all to 3 = almost every day). Ratings were summed with higher score reflecting increased depressive symptoms. Internal reliability was good (α = 0.85).
      Peritraumatic distress symptoms were assessed with the 13-item Peritraumatic Distress Inventory (PDI).
      • Brunet A
      • Weiss DS
      • Metzler TJ
      • et al.
      The peritraumatic distress inventory: a proposed measure of PTSD criterion A2.
      Participants rated their symptoms on a 5-point scale (0 = not at all true to 4 = extremely true). Ratings were summed with higher scores reflecting increased distress. Internal reliability was good (α = 0.84).

      RESULTS

      As typical, respondents felt on average younger than their age (M = 2.45 ± 0.51). Although the mean loneliness (M = 2.28 ± 0.90) and psychiatric symptom scores (GAD-7: M = 2.95 ± 3.82, PHQ-9: M = 3.33 ± 4.10, PDI: M = 9.45 ± 6.51) were generally low, there was marked variability among respondents.
      Loneliness was positively correlated with GAD-7, PHQ-9, and PDI (r(273) = 0.31, r(273) = 0.30, r(272) = 0.37, respectively, all p's <0.001,). Feeling older was also positively correlated with GAD-7, PHQ-9, and PDI (r(270) = 0.28, r(270) = 0.23, r(270) = 0.25, respectively, all p's <0.001).
      Few participants reported being tested positive for the coronavirus or being in self-isolation (n = 46, 16.6%), yet most knew someone who tested positive or was in self-isolation (n = 166, 59.9%). All respondents reported changing at least one behavior due to the pandemic (ranging from buying more food and water than usual: n = 91, 32.9%, to going out less frequently: n = 246, 88.8%). For additional descriptive statistics see Supplementary file.
      To test the study's hypotheses, we performed three hierarchical regression analyses. Significant interactions were probed using PROCESS.
      • Hayes AF
      Introduction to Mediation, Moderation, and Conditional Process Analysis: A Regression-Based Approach.
      Psychiatric symptoms (GAD-7, PHQ-9, and PDI) were regressed on background characteristics (age, gender, education, and marital status) in Step 1, variables related to COVID-19 exposure and potential complications (self-rated health, chronic medical conditions related to COVID-19 complications, COVID-19 pandemic related events, and behavioral change due to the pandemic) in Step 2, loneliness in Step 3, subjective age in Step 4, and the Loneliness*Subjective age interaction in Step 5.
      Results reveal that after controlling for demographics and COVID-19-related variables, those reporting feeling lonely (ΔR2 ranged 0.07–0.10) and those feeling older (ΔR2 ranged 0.01–0.04), also reported higher symptoms. Furthermore, all three Loneliness*Subjective age interactions were significant, explaining an additional 3%–4% variance in psychiatric symptoms (Table 1).
      TABLE 1Hierarchical Linear Regression Predicting Psychiatric Symptoms
      GAD-7PHQ-9PDI
      B (SE)βtB (SE)βtB (SE)βt
      Step 1ΔR2 = 0.07, F(4,255) = 4.62
      p ≤0.01.
      ΔR2 = 0.07, F(4,255) = 4.73
      p ≤0.01.
      ΔR2 = 0.07, F(4,255) = 4.77
      p ≤0.01.
      Age−0.03 (.03)−0.06−0.95−0.04 (0.04)−0.06−0.98−0.11 (0.06)−0.12−1.93
      Gender (woman)1.18 (0.53)0.14
      p ≤0.05.
      2.251.35 (0.56)0.15
      p ≤0.05.
      2.421.60 (0.90)0.111.78
      Education−1.03 (0.27)−0.23
      p ≤0.001.
      −3.81−1.07 (0.28)−0.23
      p ≤0.001.
      −3.74−1.70 (0.46)−0.23
      p ≤0.001.
      −3.68
      Marital status (married)0.42 (0.54)0.050.770.23 (0.57)0.030.40−0.13 (0.93)−0.01−0.14
      Step 2ΔR2 = 0.01, F(4,251) = 0.80ΔR2 = 0.03, F(4,251) = 1.99ΔR2 = 0.05, F(4,251) = 3.33
      p ≤0.05.
      Subjective health−0.30 (0.30)−0.07−1.02−0.67 (0.31)−0.15
      p ≤0.05.
      −2.13−1.39 (0.50)−0.20
      p ≤0.01.
      −2.77
      Chronic conditions related to COVID-19 complications−0.43 (0.56)−0.050.76−0.79 (0.58)−0.10−1.35−1.71 (0.94)−0.13−1.83
      COVID-19 pandemic related events0.11 (0.22)0.030.460.11 (0.24)0.030.46−0.19 (0.38)−0.03−0.50
      Behavioral change due to COVID-19 pandemic0.12 (0.10)0.081.270.17 (0.10)0.101.630.35 (0.17)0.13
      p ≤0.05.
      2.11
      Step 3ΔR2 = 0.08, F(1,250) = 23.31
      p ≤0.001.
      ΔR2 = 0.07, F(1,250) = 22.05
      p ≤0.001.
      ΔR2 = 0.10, F(1,250) = 32.10
      p ≤0.001.
      Loneliness1.25 (0.26)0.29
      p ≤0.001.
      4.821.28 (0.27)0.28
      p ≤0.001.
      4.702.43 (0.43)0.33
      p ≤0.001.
      5.66
      Step 4ΔR2 = 0.04, F(1,249) = 12.30
      p ≤0.01.
      ΔR2 = 0.01, F(1,249) = 3.88
      p ≤0.05.
      ΔR2 = 0.02, F(1,249) = 7.33
      p ≤0.01.
      Subjective age1.64 (0.47)0.22
      p ≤0.01.
      3.510.99 (0.50)0.13
      p ≤0.05.
      1.972.11 (0.78)0.17
      p ≤0.01.
      2.71
      Step 5ΔR2 = 0.03, F(1,248) = 9.96
      p ≤0.001.
      ΔR2 = 0.04, F(1,248) = 13.17
      p ≤0.001.
      ΔR2 = 0.04, F(1,248) = 15.21
      p ≤0.001.
      Loneliness X subjective age1.14 (0.36)0.20
      p ≤0.01.
      3.151.40 (0.38)0.23
      p ≤0.001.
      3.632.34 (0.60)0.24
      p ≤0.001.
      3.90
      Full modelR2 = 0.23, F(11,248) = 6.67
      p ≤0.001.
      R2 = 0.22, F(11,248) = 6.53
      p ≤0.001.
      R2 = 0.28, F(11,248) = 8.91
      p ≤0.001.
      Notes:N = 260. All continuous variables were mean-centered before analyses. In each subsequent step, only the new variables are shown (and not those from previous steps). df for t test values are identical to the denominator df noted in each step (df2). We have corrected for our multiple tests using the Benjamini and Hochberg's false discovery rate method.
      • Benjamini Y
      • Hochberg Y
      Controlling the false discovery rate: a practical and powerful approach to multiple testing.
      All three interactions remained significant (interaction p value for GAD-7, PHQ-9, and PDI was 0.001, 0.0004, and 0.0003, respectively). GAD-7 = anxiety symptoms; PHQ-9 = depressive symptoms; PDI, peritraumatic symptoms.
      a p ≤0.05.
      b p ≤0.01.
      c p ≤0.001.
      Thus, when subjective age was +1 SD above the average (i.e., having an older subjective age), the relationship between loneliness and psychiatric symptoms was strong (GAD-7: B = 1.70, t(248) = 5.62, p <0.001; PHQ-9: B = 1.88, t(248) = 5.86, p <0.001; PDI: B = 3.42, t(248) = 6.82, p <0.001). However, for young subjective ages (−1 SD below the average) the loneliness-psychiatric symptoms association was nonsignificant (GAD-7: B = 0.51, t(248) = 1.56, p = 0.12; PHQ-9: B = 0.43, t(248) = 1.23, p = 0.22; PDI: B = 0.98, t(248) = 1.81, p = 0.07) (Fig. 1).
      Figure 1
      Figure 1The interaction between loneliness and subjective age on (a) anxiety symptoms (GAD-7), (b) depressive symptoms (PHQ-9), and (c) peritraumatic symptoms (PDI).

      CONCLUSIONS

      To the best of our knowledge, this is the first study assessing the psychiatric correlates of loneliness among older adults during the COVID-19 pandemic. As hypothesized, the association between loneliness and psychiatric symptoms was significant and robust only among participants with older subjective ages. Among those with young subjective ages, there were no adverse correlates of loneliness. According to recently proposed criteria,
      • Bodner TE
      Standardized effect sizes for moderated conditional fixed effects with continuous moderator variables.
      the current standardized effect sizes for these moderation effects may be considered large.
      These findings extend previous evidence highlighting the moderating effect of subjective age when considering the outcomes of stress.
      • Stephan Y
      • Sutin AR
      • Terracciano A
      Determinants and implications of subjective age across adulthood and old age.
      Future studies should examine the possible mechanisms through which subjective age moderates the effect of loneliness on psychiatric symptomatology. We postulated the straightforward mechanism of internalization of negative age stereotype.
      • Stephan Y
      • Sutin AR
      • Terracciano A
      Determinants and implications of subjective age across adulthood and old age.
      Yet other possibilities may exist, such as negative biological mechanism and other behavioral concomitants of old age identity.
      • Stephan Y
      • Sutin AR
      • Terracciano A
      Determinants and implications of subjective age across adulthood and old age.
      Our findings should be assessed in light of the study's limitations. The current design was cross-sectional precluding conclusions regarding causality. Moreover, the online design biased the sample towards populations with an access to or literacy in digital resources and those who may be more socially connected, at least virtually, and thus may experience lower loneliness. Finally, there was no measurement of prepandemic levels of loneliness and distress.
      Still the current preliminary findings may inform screening and interventions with older adults both during the COVID-19 pandemic, and probably in assisting with post-COVID-19 damage control. Subjective age can offer some direction in identifying older adults at high risk to effects of loneliness. Moreover, online or telephone interventions targeting both loneliness
      • Jeste DV
      • Lee EE
      • Cacioppo S
      Battling the modern behavioral epidemic of loneliness: suggestions for research and interventions.
      and age identity
      • Stephan Y
      • Sutin AR
      • Terracciano A
      Determinants and implications of subjective age across adulthood and old age.
      may be provided to older adults enduring imposed isolation in order to bolster therapeutic effects.

      AUTHOR CONTRIBUTIONS

      All authors substantially contributed to the conception and design of the study and to the acquisition of data. AS performed the analysis, interpreted the data and drafted the work; all authors performed critical revision of the paper for important intellectual content and finally approved of the version to be published.
      All authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

      Disclosure

      No disclosures/conflict of interest to report.

      Appendix. SUPPLEMENTARY MATERIALS

      References

        • Brooks SK
        • Webster RK
        • Smith LE
        • et al.
        The psychological impact of quarantine and how to reduce it: rapid review of the evidence.
        Lancet. 2020; 395: 912-920
        • Vahia IV
        • Blazer DG
        • Smith GS
        • et al.
        COVID-19, mental health and aging: a need for new knowledge to bridge science and service.
        Am J Geriatr Psychiatry. 2020;
        • Jeste DV
        • Lee EE
        • Cacioppo S
        Battling the modern behavioral epidemic of loneliness: suggestions for research and interventions.
        JAMA Psychiatry. 2020; 77: 553-554
        • Stephan Y
        • Sutin AR
        • Terracciano A
        Determinants and implications of subjective age across adulthood and old age.
        in: Ryff C Krueger RF The Oxford Handbook of Integrative Health Science. Oxford University Press, New York, NY2018: 87-96 (Edited by)
        • Kastenbaum R
        • Derbin V
        • Sabatini P
        • et al.
        “The ages of me”: toward personal and interpersonal definitions of functional aging.
        Int J Aging Hum Dev. 1972; 3: 197-211
        • Hughes ME
        • Waite LJ
        • Hawkley LC
        • et al.
        A short scale for measuring loneliness in large surveys: results from two population-based studies.
        Res Aging. 2004; 26: 655-672
        • Spitzer RL
        • Kroenke K
        • Williams JB
        • et al.
        A brief measure for assessing generalized anxiety disorder: the GAD-7.
        Arch Intern Med. 2006; 166: 1092-1097
        • Kroenke K
        • Spitzer RL
        • Williams JB
        The PHQ‐9: validity of a brief depression severity measure.
        J Gen Intern Med. 2001; 16: 606-613
        • Brunet A
        • Weiss DS
        • Metzler TJ
        • et al.
        The peritraumatic distress inventory: a proposed measure of PTSD criterion A2.
        Am J Psychiatry. 2001; 158: 1480-1485
        • Hayes AF
        Introduction to Mediation, Moderation, and Conditional Process Analysis: A Regression-Based Approach.
        Guilford Press, New York, NY2013
        • Bodner TE
        Standardized effect sizes for moderated conditional fixed effects with continuous moderator variables.
        Front Psychol. 2017; 21: 562
        • Benjamini Y
        • Hochberg Y
        Controlling the false discovery rate: a practical and powerful approach to multiple testing.
        J R Stat Soc B. 1995; 57: 289-300