Some 14–17% of adults over 65 are lonely. Social isolation and the subjective experience of loneliness can increase the risk of poor health outcomes, including anxiety, depression, suicide, sleep problems and premature mortality. Cohousing is a form of grouped housing designed and managed by those who reside within it. We consider whether this approach may have beneficial effects in alleviating or protecting from loneliness in older people. This is part one of a two-part article.
A novel approach in older persons’ housing is a recently established cohousing development, ‘New Ground’ in London, UK. Cohousing is a form of grouped housing designed and managed by those who reside within it. Further characteristics include resident selection, organisational shared values, a focus on social interaction and mutual support, and a mixture of private and shared spaces and facilities.1 We consider whether this approach may have beneficial effects in alleviating or protecting from loneliness in older people.
Social isolation and loneliness have detrimental effects on health and quality of life and are increasingly being recognised as a public health concern. Loneliness and social isolation increase the risk of anxiety, depression, suicide, sleep problems and cardiovascular disease.2–5 The risk of Alzheimer’s disease is more than double in lonely compared with non-lonely people, and loneliness is associated with more rapid cognitive decline.6 These results were sustained when researchers controlled for social isolation.
Loneliness is a subjective negative experience, the discrepancy between the level of social connectedness a person desires and what they perceive they have.7 Social isolation is an objective paucity of contacts and interactions between a person and a social network.7 The increased likelihood of seven-year mortality is 26% for loneliness, 29% for social isolation and 32% for living alone, in studies adjusting for age, sex and health conditions.8
Mechanisms behind adverse health effects include changes in health behaviour such as diet, alcohol and smoking, stress, likelihood of seeking emotional support, immune and cardiovascular system changes and worsened sleep along with consequent metabolic, hormonal and neurological changes.9,10
Some 14-17% of adults over 65 are lonely.11 In the UK, rates of loneliness peak under age 25 and over 75.11 The quality of social relationships rather than quantity may be more important in loneliness in older adults.11 Females are at higher risk than men, and females’ risk increases earlier (over age 55 compared with over 75 for men), perhaps indicating different causal mechanisms related to illness, spousal death or entry into care.11 Major life changes such as retirement, bereavement or break up of relationships also contribute, as can physical and mental health problems.11–15
Potentially modifiable risk factors include living alone, social isolation and where one lives; building structures, local amenities and neighbourliness all have an impact.13,16,17 Some believe societal changes such as commodification and focus on efficiency, with resulting shifts in family life, local institutions, care delivery and use of information and communications technology (ICT) risk increasing social isolation among older people.18
Psychological theories state that loneliness increases maladaptive social cognitions, including cynicism, mistrust, negative self-appraisals and expectations of rejection, which serve to increase the likelihood of rejection.12
Interventions towards reducing loneliness can be grouped into those that (1) improve social skills, (2) enhance social support, (3) increase opportunities for social contact, and (4) address maladaptive social cognition.12 Dominant approaches in elders include telephone support, support groups, identification of at-risk individuals, crisis interventions with case management, facilitated discussion groups, education programmes, retirement village living, and ICT provision and training.19
Promising interventions use more than one method and aim to be effective across a broad range of outcomes. Including group activities, targeting specific groups and allowing participants to control and be involved in the planning, implementation and evaluation appear to be beneficial. Carefully selected and trained facilitators or coordinators should be used and programmes should build on the capacity of existing community resources. Interventions should include process evaluation.19–21
Interventions must support self-efficacy and empower people to make and develop peer-support.22 Loneliness is dynamic throughout life and will not always affect the same people.23 One-off interventions are unlikely to be sufficient.
Recent focus on the topic has resulted in The Jo Cox Commission on Loneliness, and the UK government appointing a ministerial lead.24 However, with older people being the fastest-growing section of the community—the proportion of people over 85 is expected to double within two decades—stretched social care systems will require innovative solutions.25
Cohousing originated in Denmark in the 1960s, as a means of creating social and economic advantages through shared goods, services, meals and chores, stronger social support networks for independent living, and safety and security.26 Chiodelli & Baglione identified five characteristics that define cohousing: (i) communitarian multi-functionality, (ii) constitutional and operational rules of a private nature, (iii) residents’ participation and selforganisation, (iv) residents’ self-selection and (v) value characterisation.27
‘New Ground’ is the only established cohousing development for older people in the UK, completed in November 2016.28 It was developed by the Older Women’s Cohousing (OWCH) group, with support from three charities, and includes 25 self-contained one to three-bedroom flats with shared spaces including a common room, guest room, laundry and gardens. Seventeen flats are owner-occupied and eight are social housing.
OWCH has an elected management committee, and decisions are made by the resident group via monthly meetings. One of a number of policies concerns mutual support.29 Everyone is expected to contribute through a series of work teams, such as for cleaning, gardening, finance, membership and communications. There is a weekly communal meal and social activity programme.
The scheme is exclusively for women aged 50 or more; nominated members of OWCH who have been through a selection process and universally accepted. A group of non-resident members visit for events and activities and can fill vacancies as they arise. This helps address criticisms of cohousing developments in other countries that have appeared poorly integrated with surrounding neighbourhoods.27 OWCH residents are from a diverse range of career backgrounds. Ages range from 52 to 88, median 71.30 Also 23 out of 26 are White British, two are Iranian refugees.
OWCH members invited the local Older Adults Community Mental Health Team to deliver a 20-minute talk about dementia and share a meal. Residents revealed a perceived lack of knowledge and fear of developing dementia, as well as a desire to use their living environment to reduce their risk and remain independent for as long as possible. Alzheimer’s Disease Knowledge Scale (ADKS) scores were mean 22/30 (74%) immediately before the session and 25/30 (85%) after three days (n=18, P=0.02). Expected ADKS scores for students, senior centre staff, dementia caregivers, older adults and dementia professionals are 20.2, 20.2, 22.7, 24.1 and 27.4 respectively.31 OWCH women’s scores reflect a mixed age group and educational background and improved following the training.
Loneliness and social isolation are common in UK elders and possibly growing. Innovative public health and social care solutions are needed. People moving post-retirement, particularly when by choice, can have beneficial effects towards health and social isolation if the housing and environment are suitable to the person’s needs. Cohousing may have the potential to promote socialisation and neighbourliness and improve factors affecting loneliness such as helping residents feel valued, useful and part of a community. Policymakers should consider the potential health and social benefits of cohousing to support housing strategies.
Part two of this article will discuss post-retirement migration as well as the architecture and organisational structure of the project.
Dr Helen Hopwood, ST4 Psychiatry trainee, Barnet Enfield and Haringey Mental Health Trust
Dr Farhana Mann, Wellcome clinical research training fellow at the Division of Psychiatry, UCL
Conflict of interest: none declared
Acknowledgements: The authors thank Dr Melissa Fernandez Arrigoitia, Dr Vivienne Watkin and Dr Robert Tobiansky for their guidance.
16. Rantakokko M, Iwarsson S, Vahaluoto S, et al. Perceived Environmental Barriers to Outdoor Mobility and Feelings of Loneliness Among Community-Dwelling Older People. Journals Gerontol Ser A Biol Sci Med Sci 2014; 69: 1562–68
18. Clifton J. Social Isolation Among Older Londoners. 2011 http://www.ainesestrie.qc.ca/pdf/social_isolation_oct2011.pdf (accessed Feb 9, 2018)
21. Rutter J, Andrew H. Home Sweet Home? The nature and scale of the immigration of older UK nationals back to the UK. 2009 https://www.ippr.org/files/images/media/files/project/2011/12/home_sweet_home.pdf (accessed Feb 9, 2018)
24. Jo Cox Commission on Loneliness. Combatting loneliness one conversation at a time. 2017 https://www.ageuk.org.uk/globalassets/age-uk/documents/reports-and-publications/ reports-and-briefings/active-communities/rb_dec17_jocox_ commission_finalreport.pdf (accessed Feb 6, 2018)
25. Office for National Statistics. Overview of the UK population - Office for National Statistics. 2017. https://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationestimates/articles/overviewoftheukpopulation/ july2017 (accessed Feb 6, 2018)
28. UK Cohousing. UK Cohousing Directory - UK Cohousing Network. 2017. https://cohousing.org.uk/information/ukcohousing-directory/ (accessed Feb 9, 2018)
29. OWCH (Older Women’s Co-Housing) Group. Policies. 2016. http://www.owch.org.uk/policies/ (accessed Feb 9, 2018)
30. Harris J. We need to talk about ageing – and it’s about far more than the NHS. Guard. 2018. https://www.theguardian.com/commentisfree/2018/feb/04/ageing-nhs-loneliness-cohousing (accessed Feb 10, 2018).