65+ and lonely? Don’t talk to your doctor about another prescription

Lonely, older adults are nearly twice as likely to use opioids to ease pain and two-and-a-half times more likely to use sedatives and anti-anxiety medications, putting themselves at risk for drug dependency, impaired attention, falls and other accidents, and further cognitive impairment, according to a study by researchers at UC San Francisco.

The study found that just over half of 6,000 respondents in a nationally representative survey of seniors living independently were not lonely, while 40 percent were moderately lonely, and 7 percent were highly lonely.

The proportion of seniors in each group who had prescriptions for opioids and anti-anxiety medications and sedatives, which included drugs like Valium, Xanax, BuSpar and Ambien, correlated with their degree of loneliness, according to the study, which publishes in JAMA Internal Medicine on June 26, 2021.

“There’s a misconception that as we age, we become more withdrawn and less sociable,” said first author Ashwin Kotwal, MD, of the UCSF Division of Geriatrics and of the San Francisco VA Medical Center. “In fact, older people are more socially active than other age groups and frequently play major roles in their communities. When older people are not socially active, we need to recognize that there’s a problem.”

The researchers used data from the National Social Life, Health and Aging Project, a population-based study of health and social factors, and checked each participant’s medications if they were used “on a regular schedule, like every day or every week.” The participants’ average age was 73; 46 percent were male, and 84 percent were white (7 percent were Black and 6 percent were Hispanic).

The researchers found that 6 percent of the non-lonely group used prescription opioids, versus 8 percent for the moderately lonely group and 11 percent for the highly lonely group. For anti-anxiety medications and sedatives—which includes anti-cholinergic drugs, like Valium, Unisom and tricyclic antidepressants, which have been associated with a higher risk for dementia—9 percent of the non-lonely group used them, versus 13 percent for the moderately lonely group and 23 percent for the highly lonely group.

Similar patterns were found with antidepressants and NSAIDs, prescription and over-the-counter painkillers that may cause ulcers and bleeding in long-term use by older adults. The highly lonely group was also more likely to be on five or more medications—58 percent versus 46 percent for the non-lonely participants.

Replacing Prescriptions with Social Contact

Kotwal advocates for fewer prescriptions of psychotropic drugs for older adults who are lonely, and in its place “social prescribing” to local resources in the community. This can be done by “link workers,” based in primary care practices or within the community, with connections to amenities like senior centers, exercise classes, grief groups or volunteer programs.

He notes that the pandemic has taken the stigma out of loneliness, giving older adults an opportunity to discuss their feelings in clinic. Asking patients what might help can be a good first step to referring them to programs that might fit their needs.

“We don’t want to pathologize loneliness. Most people experience loneliness at some point in their lives, but when experiences of loneliness persist for many months or years, it can cause physiologic changes, such as a ramped-up stress response, sleep problems, and even heart disease,” said Kotwal. “And, a lack of social contact can erode our social skills, making it more difficult over time to connect with others and creating a vicious cycle.”

De-Prescribing a Challenge for Patients in Distress

While physicians are well aware of the dangers of prescribing medications that should not be used in the long term, Kotwal noted that it “takes time and effort to de-prescribe,” and switching a drug that acts promptly with one that may take several weeks to have an effect may be very challenging to patients in distress.

In busy practices with complex patients, contraindications may not come to light until a patient is suddenly hospitalized, said Kotwal. “It’s only then that we might find out that a patient’s prescriptions include Valium and he’s been taking it for more than 20 years.”

A recent previous study, also led by Kotwal, found that in the last four years of life, 19 percent experienced social isolation, 18 percent were lonely and 5 percent experienced both social isolation and loneliness. Factors associated with loneliness included female gender, pain, incontinence and cognitive impairment.