Loneliness associated with poorer cognitive function, mental health and physical health in older people with HIV

Loneliness in older HIV-positive adults is associated with reduced cognitive function as well as poorer mental and physical health, according to Canadian research presented to the recent Aging and HIV Workshop in New York. Approximately two-thirds of study participants reported loneliness, which was associated with both HIV-related and lifestyle factors.

“The results support that physical symptoms (e.g. pain, fatigue), apathy, stigma, and restricted social network contribute to loneliness,” concluded Marianne Harris and colleagues. “Loneliness has consequences for reduced activity, poor lifestyle choices, impaired cognition, stress, and depression, all of which contribute to poor quality of life.”

Loneliness has been associated with poor health in the general population, especially in older individuals. However, little is known about the prevalence of loneliness, its risk factors and impact on health and quality of life in people with HIV. People with HIV may be at increased risk of loneliness because of stigma, depression, substance use, lack of social connections and physical symptoms.

To establish a clearer understanding of these issues, investigators analysed cross-sectional data from participants in the Positive Brain Health Now cohort. Participants were HIV-positive people aged 35 years and older who received outpatient care between 2013 and 2016 at five HIV outpatient clinics in Vancouver, Toronto, Hamilton and Montreal.

Data were collected using interviews and self-report questionnaires. Loneliness was assessed using a single question, “Do you find yourself feeling lonely: quite often, sometimes or almost never?” Cognitive function, mental health, self-rated health and quality of life were measured using validated tests.

All the participants had been diagnosed with HIV for at least one year. Individuals with dementia or a central nervous system disorder were excluded. A total of 836 people were included – most (85%) were men, approximately three-quarters were Caucasian and the mean age was 52 years.

Almost two-thirds (64%) reported loneliness, including 18% who said they were quite often lonely and 46% who were lonely some of the time.

People were more likely to report loneliness if they were not having enough money to meet basic needs (p < 0.001). Loneliness was more common in individuals with a higher number of HIV-related symptoms (p < 0.001), more severe symptoms (p < 0.001), weakness as a symptom (p < 0.001) or lung disease (p < 0.05).

Several lifestyle factors were also associated with loneliness, including reduced physical activity (p < 0.001), watching more hours of TV (p < 0.05) and opioid use (p < 0.05).

Loneliness was associated with poorer cognitive function and more self-reported cognitive concerns (both p < 0.001). On four different validated scales, people who were quite often lonely had poorer mental health and wellbeing (all p < 0.001), including symptoms of depression, stress and anxiety.

Relatively few people who were often lonely rated their health as very good or excellent (25.0%), compared to those who were never lonely (61.3%). Similarly, quality of life was rated as very good or excellent by 37.8% of those who were quite often lonely and 89.8% of those who were never lonely.

The investigators developed a model to better understand how loneliness was associated with poorer health in people with HIV:

• Contributors to loneliness: stigma, having fewer than five close friends or relations, pain, fatigue, and not working or volunteering.
• Consequences of loneliness: reduced physical activity, more hours spent watching TV, opioid use, reduced cognitive function, increased stress, and poorer mental health.
• Downstream effect: poorer self-rated health and poorer quality of life.

The investigators acknowledge that their findings are limited by the composition of the study population (mostly male and white). The cross-sectional design meant they were unable to definitively determine the direction of the association between loneliness and poorer outcomes.

They call for more research, especially qualitative studies assessing experiences of loneliness from the perspective of patients.

The authors also believe their findings have clear implications for models of HIV care, showing the importance of enhanced social care for people with HIV, especially older individuals. Interventions to engage people in socially meaningful activities should be developed for older adults living with HIV, they say.