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Considering the Impact of Research Assessments: A Commentary on “COVID-19 Related Loneliness and Psychiatric Symptoms Among Older Adults: The Buffering Role of Subjective Age”

  • Kimberly A. Van Orden
    Correspondence
    Send correspondence and reprint requests to Kimberly A. Van Orden, Ph.D., University of Rochester School of Medicine & Dentistry, 300 Crittenden Blvd, Box PSYCH, Rochester, NY 14642-8409.
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    University of Rochester School of Medicine & Dentistry (KVO), Rochester, NY
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Published:August 10, 2020DOI:https://doi.org/10.1016/j.jagp.2020.08.003
      Social connections are essential for health and well-being. Social isolation and loneliness are potent predictors of well-being, health, functioning, and longevity.
      • Holt-Lunstad J
      • Robles TF
      • Sbarra DA
      Advancing social connection as a public health priority in the United States.
      Despite the public health significance of social isolation and loneliness, there are few evidence-based strategies to improve social connections.
      • Holt-Lunstad J
      • Robles TF
      • Sbarra DA
      Advancing social connection as a public health priority in the United States.
      The COVID-19 pandemic has increased the urgency for identifying evidence-based strategies for improving social connections, including compensating for barriers to connectedness such as physical distancing.
      • Wu B.
      Social isolation and loneliness among older adults in the context of COVID-19: a global challenge.
      Given that social isolation and loneliness can arise from multiple biopsychosocial pathways, it could be beneficial to identify modifiable targets for reducing loneliness and isolation—and/or reducing their impact on mental health—in order to personalize interventions.
      • Lim MH
      • Eres R
      • Vasan S
      Understanding loneliness in the twenty-first century: an update on correlates, risk factors, and potential solutions.
      Shrira and colleagues
      • Shrira A
      • Hoffman Y
      • Bodner E
      • et al.
      COVID-19-related loneliness and psychiatric symptoms among older adults: the buffering role of subjective age.
      examine one potential psychosocial condition that may magnify negative mental health effects of loneliness during the pandemic – greater subjective age (i.e., feeling older than one's chronological age). They present results of a cross-sectional, online study examining associations between mental health symptoms and loneliness among older adults during the COVID-19 pandemic. They hypothesized that loneliness during the pandemic would be more strongly associated with mental health symptoms among older adults who reported greater subjective age. They examined the two-way interaction of subjective age and loneliness with three mental health indicators—depressive symptoms, anxiety symptoms, and trauma symptoms and found weaker associations between loneliness and these mental health symptoms among those with lower perceived age. These results suggest a potential buffering effect of lower subjective age. The authors suggest that subjective age could be used to identify older adults at elevated risk for negative health outcomes due to loneliness and that subjective age could be a useful intervention target. This study raises intriguing questions about social connectedness in later life.
      First, what is the most useful and accurate measurement strategy to assess loneliness during the pandemic? Shrira and colleagues administered the UCLA Loneliness Scale and instructed participants to base their responses on experiences during the pandemic. Does this necessarily mean that responses to the loneliness questions were influenced by the pandemic? While we know that loneliness is associated with numerous adverse outcomes, the field still has much to learn about how we define and measure loneliness. Prevalence rates of loneliness vary depending on whether the word “loneliness” is used in the scale. Further, there may be several dimensions to loneliness (e.g., emotional versus social loneliness). Chronic and transitory loneliness may be associated with differential outcomes. Finally, loneliness may be a state that is particularly influenced by the act of asking questions about it and encouraging participants to reflect on their experiences. Results from Shrira and colleagues’ study should be considered in the context of these complexities regarding the assessment of loneliness.
      Assessment issues are also relevant for the construct of subjective age. While subjective age is a long-standing construct in gerontology that is a robust predictor of health and well-being,
      • Alonso Debreczeni F
      • Bailey PE
      A systematic review and meta-analysis of subjective age and the association with cognition, subjective wellbeing, and depression.
      as with loneliness, assessment issues should be considered when interpreting and applying findings. Experiencing age discrimination as well as physiological markers of health (lower peak expiratory flow, lower grip strength, and higher waist circumference) have been shown to be associated with older subjective age, controlling for sociodemographic factors, self-rated health, and depressive symptoms.
      • Stephan Y
      • Sutin AR
      • Terracciano A
      How old do you feel? The role of age discrimination and biological aging in subjective age.
      Gendron and colleagues suggest that studies such as this one indicate that subjective age is likely an indicator of the degree to which someone has internalized ageism and that asking participants to consider how old they feel may be perpetuating ageist messages.
      • Gendron TL
      • Inker J
      • Welleford A
      "How old do you feel?" The difficulties and ethics of operationalizing subjective age.
      They pose the following thought experiment: imagine that you asked research participants, “how female do you feel” or “how white do you feel?” Without asking follow-up questions, would you know how to interpret their responses? Would those questions yield meaningful data, and would you know what you were measuring? Given the dominant view worldwide of aging as a negative experience, they suggest: “the question ‘how old do you feel?’ actually may be interpreted as “how (sick, frail, tired, slow) do you feel?” (p. 620). In that case, assessing subjective age could reinforce ageist messages. This is not to say that studies assessing subjective age are unethical, but that as a field, we should consider this long-standing construct and whether it serves goals of social justice for older adults as we design our studies and speak with our patients. Results from Shrira and colleagues’ study should also be considered in the context of these complexities regarding the assessment of subjective age.
      The possibility that subjective age is a marker of internalized ageism has implications for taking actionable steps based on studies linking greater subjective age to negative health outcomes. Shrira and colleagues suggest targeting age identity could be useful in mitigating negative effects of loneliness. What would that entail? Would psychotherapists encourage patients to consider the many ways in which they live vibrant, active lives and thus challenge their beliefs that they are “old?” This type of intervention assumes that perceiving oneself as older is necessarily negative. Gendron and colleagues
      • Gendron TL
      • Inker J
      • Welleford A
      "How old do you feel?" The difficulties and ethics of operationalizing subjective age.
      suggest that we consider: “What does old feel like? Is feeling old intended to capture the accumulation of wisdom, life experience, and knowledge, or is feeling old intended to capture physical and/or mental decline?” Would intervening to reduce someone's subjective age send a message that feeling older is something to avoid? Could that intervention possibly have an iatrogenic effect? It seems that directly targeting internalized ageism, rather than age identity, might promote health without creating unintended side effects.
      In my laboratory, the HOPE Lab (Helping Older People Engage), we study interventions to reduce loneliness. Most of our participants report that they have rarely, if ever, reflected on the effect that loneliness has on their health, and that engaging in study visits results in increased awareness of their social health and produces behavior change (i.e., increased social activity)—an illustration of the “treatment utility of assessment.”
      • Hayes SC
      • Nelson RO
      • Jarrett RB
      The treatment utility of assessment. A functional approach to evaluating assessment quality.
      With regards to social connections, asking questions about the phenomenon in a research context may result in increased awareness and healthy changes. With regards to subjective age, asking questions about this phenomenon in a research context could unintentionally reinforce internalized ageism and have negative effects. One actionable step to take as researchers is to build time into our study visits to ask participants if they have reactions—negative or positive—to our assessment instruments and if there is anything we could do differently to improve their experiences as participants. Our older participants have a wealth of experience and expertise to bring to our research and I am humbled by what they teach me every day.

      Author contributions

      Kim Van Orden is responsible for the entire manuscript.

      Disclosure

      Kim Van Orden is responsible for the entire manuscript and has no conflicts of interest to disclose.

      Appendix. SUPPLEMENTARY MATERIALS

      References

        • Holt-Lunstad J
        • Robles TF
        • Sbarra DA
        Advancing social connection as a public health priority in the United States.
        Am Psychol. 2017; 72 (PMC5598785): 517-530https://doi.org/10.1037/amp0000103
        • Wu B.
        Social isolation and loneliness among older adults in the context of COVID-19: a global challenge.
        Glob Health Res Policy. 2020; 5 (PMC7272234): 27https://doi.org/10.1186/s41256-020-00154-3
        • Lim MH
        • Eres R
        • Vasan S
        Understanding loneliness in the twenty-first century: an update on correlates, risk factors, and potential solutions.
        Soc Psychiatry Psychiatr Epidemiol. 2020; 55: 793-810https://doi.org/10.1007/s00127-020-01889-7
        • Shrira A
        • Hoffman Y
        • Bodner E
        • et al.
        COVID-19-related loneliness and psychiatric symptoms among older adults: the buffering role of subjective age.
        Am J Geriatr Psychiatry. 2020; 28 (PMC7251397): 1200-1204https://doi.org/10.1016/j.jagp.2020.05.018
        • Alonso Debreczeni F
        • Bailey PE
        A systematic review and meta-analysis of subjective age and the association with cognition, subjective wellbeing, and depression.
        J Gerontol B Psychol Sci Soc Sci. 2020; https://doi.org/10.1093/geronb/gbaa069
        • Stephan Y
        • Sutin AR
        • Terracciano A
        How old do you feel? The role of age discrimination and biological aging in subjective age.
        PLoS One. 2015; 10 (PMC4349738)e0119293https://doi.org/10.1371/journal.pone.0119293
        • Gendron TL
        • Inker J
        • Welleford A
        "How old do you feel?" The difficulties and ethics of operationalizing subjective age.
        Gerontologist. 2018; 58: 618-624https://doi.org/10.1093/geront/gnx098
        • Hayes SC
        • Nelson RO
        • Jarrett RB
        The treatment utility of assessment. A functional approach to evaluating assessment quality.
        Am Psychol. 1987; 42: 963-974