Anne rises twice from her chair when called. Her first attempt gets her only part way up before gravity sends her plummeting back toward the hard waiting-room chair. However, with no control over her descent, she has built up enough energy to rebound to a standing position in an act that looks ironically well rehearsed.
She glances quickly to ensure I’m still there. “I’m coming,” Anne says. Then habit and the hunch of her shoulders force her to look down as she tentatively starts to move forward. The flimsy, black fabric fronts of her ill-fitting slippers seem barely strong enough to contain the hammer toes and bunions bulging within. A soft, shuffling noise accompanies her slow progress.
The minutes tick by. Anne finally makes it to my office, sits, still in her stooped position, then leans in to tell me, her family physician, what brings her in today. Her wispy hair is mostly tucked under the frayed edge of a netted hat, although a small fringe surrounding her face softens the look. I can picture her over the years standing at her familiar hallway mirror checking that this hat is positioned just so over the thick brown curls she tells me she once had. Now only the tips are brown; with no recent “wash” the grey has taken over.
Anne is wearing her typical outfit. A floral blouse made of a delicate fabric that would have hung elegantly on a larger frame but is now faded and drapes loosely over her bony shoulders. As a conversation starter, I comment on the blouse’s pretty pattern. “To cover up these ugly arms,” she tells me. “Who would want to look at these?” she says, pulling up her sleeves to show me her bony arms, skin blotchy with sun damage like an artist’s palette of mottled browns.
“How are you?” I ask, knowing the answer that will come.
“Terrible” she says matter-of-factly. “How is it that I am still here? I have nothing to do. I spend the whole day just sitting by the window watching the children in the playground. I’m so lonely.”
At 95, Anne may be my oldest patient to express this sentiment but certainly far from my only one. I have heard it from patients of all ages and walks of life — sometimes they tell me directly, more often it is simply evident in their description of the struggles in their daily lives. Although it often coexists with social isolation, loneliness is a distinct entity defined “as a discrepancy between a person’s desired and actual social relationships.”1 It is a feeling we have all had at one time or another, but for some people it is a persistent and overwhelming emotion that has been linked to higher rates of mental health issues such as depression and anxiety, and other conditions such as heart disease, high blood pressure and dementia.2 The good news is that research has given loneliness the attention it deserves as an important health issue. Efforts have been made to create resources to address the needs of lonely people, with much of this work focused on services and programs to help strengthen existing relationships or build new connections.
“But Anne,” I reply, “There are lots of things you could be doing in your building. What about the weekly dinners in the room downstairs or cards on Thursdays?”
“Oh, I always bring dinner back up to my room. I don’t want to sit down there. Can’t hear properly anyway. Who is going to want to talk to me?” Anne replies. “As for cards, I don’t have nothing against those that play, but I’ve never been one for the game.” She waves her hand in a dismissive manner that contrasts sharply with the frailty of it. “I love children. I used to really enjoy looking after them. Wish I still could.” She trails off.
It’s like a scratched record that keeps repeating. We’ve had this same discussion over and over: the “solution-focused” physician in me suggesting she take advantage of the multiple services and activities that are available to her in her specialized supportive apartment building. Anne adamantly refusing any attempts to engage her in more social situations. I have struggled with this apparent discrepancy between her repeated expressions of loneliness and her avoidance of all the possible solutions.
“No one likes me in the building. I’m not rude to those people if they talk to me, I do talk back, but I’m not starting no conversations. What do I have to talk about anyway? I’m not that kind of person. Never have been, always been a bit of a loner,” Anne says.
I appreciate that Anne has hearing problems but, given her chattiness in the office, it is hard for me to believe her claim of a taciturn nature is entirely true. As for being disliked, I’ve probed into that too, and it seems to be based on an immutable self-perception that she is not worth talking to. Having known her for only 15 of her 95 years it is hard for me to know exactly what might have led to this negative self-image. At times when I am struggling to find how I can help, I shift my focus to simply learning more of her story. I ask questions about her past to understand the person behind the old face in front of me, hoping that this insight will improve my ability to help her move forward, to be less lonely. I have been struck by the neglect of her childhood — no schooling, despite, as she tells me, being “excellent at writing,” she was forced to stay home and care for her younger siblings. Then the challenges of her later life — married young, financial insecurity and being predeceased by her adult children.
Anne turns toward me — the deep wrinkles on her face like crevices created by tiny streams gradually wearing away the surface of a stone.
As I look at her, I reflect on our conversations that are always peppered with her self-deprecating remarks and wonder if we need to broaden our approaches to helping those with persistent loneliness. Social researchers have pointed to “self-disgust” as playing a pivotal role in the lives of lonely people. The emotion of disgust is thought to have evolved in humans as a form of protection against foods that might be harmful if consumed. Self-disgust is thought to arise from an interplay of hard-wired emotion, ongoing thought processes in which people compare themselves with others, and changes in self-concept over time. These result in a maladaptive form in which the disgust is directed at oneself.2 Although the research is limited, meta-analyses1,3 have found that approaches, such as cognitive behavioural therapy, that addressed these counterproductive thought patterns were more effective at treating loneliness than those that focused on social skills and engagement alone. Thinking about Anne, this makes sense. No bingo game or sit-and-stretch class is going to address the cycle created by her feelings of low self-worth. She, and patients like her, need something more. Various options, such as self-compassion–focused treatment, mindfulness training and rumination-focused cognitive behaviour therapy are still in the early stages.
Would any of this work for Anne? I admit to having my doubts as I look back at her. She is smiling now though, giggling even at my comment that I would love to have a pair of arms like hers at 95 especially since they still work so well. Her eyes briefly alight, I picture a future in which she is living independently, something she fiercely clings to, but no longer feels alone.
In the meantime, today we will chat as we usually do, about this and that — her sore joints, the support workers that are too quick to come and go, the terrible quality of delivered meals and, in listening to her, I hope at least to provide some comfort.
Footnotes
This article has been peer reviewed.
Anne’s granddaughter, who holds her power of attorney, has given consent for this story to be told.