A statement that is often repeated in discussions, lectures, and theories about aging, is that "the number-one enemy of old age is loneliness". Ari Sullivan, for example, stated that "the driving force of loneliness is that it is worse than anxiety,” and defined loneliness as "a very unpleasant experience that fails to meet the need for human intimacy” [2].

In life – and especially in the lives of the elderly – loneliness can lead to depression and crises, and it entails a host of undesirable results and consequences; all of which create a real need to deal with the issue and try to make it easier for elderly people, who must contend with this bitter enemy.

This has become even more true in the modern age, which has pushed the older members of society aside. Revered elders of the tribe no more, nowadays the elderly no longer represent wisdom, experience, and knowledge. Technology often cuts them off from society and even their immediate family, rendering them obsolete at best, and at worst – a burden. The isolation factor stands out in particular, as it affects the elderly socially, emotionally, mentally, financially, psychologically, and cognitively, making it a central element in the elderly’s behavior and social interactions.

The solutions countries worldwide, including Israel, have tried to implement over the years have varied, as they have attempted at times to take a dual-pronged approach that sought to deal with the elderly as individuals who suffer from loneliness, as well as with them as members of society who struggle with this issue within their communities.

The cultural or social aspect of this issue is very prominent on the one hand, while on the other hand, it tries to impose various kinds of “company” on the elderly – volunteers, special projects, etc., – as will be detailed below. All of these lack a comprehensive, national program that tries to deal with loneliness and its consequences on a systemic level, i.e. the state, to the individual level – the elderly and their families.

Providing services for the elderly in the context of combating loneliness raises a core dilemma: which services will be most effective in this situation – integrative or individual? For the author, it is clear that the fight against loneliness among the elderly requires a holistic approach, and hence the solution must be integrative, meaning a comprehensive national plan for the elderly sector as a whole in a given society.

It is not for nothing that the officials who put together the national plan for services for the elderly population in Israel, claim, "Among all the problems and needs that arise during the aging process, there are special problems that require specific attention due to their large scale or the special distress they entail. Contending with the issue of loneliness – due to the mental suffering and attention and scope of the phenomenon – requires the development of a special plan” [2].

This article strives to present the conclusions derived from a series of articles and studies conducted by the author on the subject of the fight against loneliness among the elderly and the guidelines for a proactive, integrative concept for the fight against loneliness in old age. The following chapters will present definitions, diagnoses, and case studies, as well as a review of professional literature on the subject of loneliness among the elderly, its consequences, and its implications on the elderly’s quality of life.

The main part of this essay will focus on the concept of an integrative plan to counter this problem in Israel as a case study; and will try to integrate the options detailed here into a tool with which it will be possible to eradicate the consequences of loneliness among older Israelis – or at least alleviate them.

The circular model that will be presented here will focus on the elderly individual as the focal of the activity pursued by all the factors making up the model, with the clear goal of eliminating the scourge of loneliness and social isolation. It is possible – and necessary – to deal with this phenomenon and its results in a centralized manner, on a national scale, and using all resources – and the sooner the better.

The article will summarize essays and studies that I have written or carried out and on which the findings of this article are based.

Having presented the need for an integrative operational concept in the fight against loneliness in old age, we will now turn our attention to the relevant definition.

The dictionary definition of “loneliness” states it is “being alone; the quality of being unfrequented, remote, and isolated” [3]. Psychologically speaking, “loneliness is a subjective, unwelcome feeling of the lack or loss of companionship, which happens when there is a mismatch between the quantity and quality of the social relationships that we have, and those that we want” [4].

Loneliness is often linked to phenomena such as anxiety, depression, and suicide, and it is always depicted as bleak. Loneliness seems to have always been a part of the human experience and it has been described in emerging historical accounts, poetry, and paintings (Edward Munch, Lars Hertervig). Loneliness is also extensively featured in classic and contemporary literature. A notable example is J. D. Salinger’s iconic novel The Catcher in the Rye, whose protagonist, Holden Caulfield, experiences loneliness as an almost constant problem, believing that death would be the only solution: "I felt so lonely… suddenly, I almost wanted to die” [5].

Over time, and with the rise of technological developments, the modern era has emerged as the "Age of Loneliness" – an era in which the phenomenon of loneliness, regardless of the age of those it befalls, has become almost an epidemic. However, loneliness has not been studied, at least not in the various disciplines in the West, until the onset of the modern era, around the 18^th century.

Various studies and existing literature on the subject offer several definitions for the concept of loneliness. The comprehensive interpretation, given in the article by Heinrich and Gullone in 2006 [6], describes it as “an unpleasant emotional experience”. Leading loneliness researchers such as Goteskyr (1965), Weiss (1973), Hartog (1980), and Perlman and Peplau (1981) found a common denominator in defining loneliness as a subjective and common phenomenon among humans, adding that it is an unpleasant experience that most people try to avoid and fight [7].

There is a fine distinction between “loneliness” and “isolation” that is often ambiguous. Already in 1963, Townsend introduced the difference as one between an objective and a subjective experience, explaining that loneliness is a subjective measure of “unwelcome, unpleasant feelings associated with having only minor contact with one’s family and community,” while social isolation is perceived as a more objective concept, based on the “quantifiable absence of contact with other people or loss of relationships.” He argues that as “the first concept is objective and the second subjective, there is no overlap between the two" [8].

Perlman and Peplau extended this distinction, defining loneliness as “an essentially subjective experience that is not synonymous with objective social isolation. People can be alone without feeling lonely, and feel lonely in a crowd" [4].

If we examine the issue in its context in the world of health, loneliness is seen as an important factor in the development of medical problems, such as psychosomatic disorders, breast cancer, cardiovascular function, and more. A recent study in Switzerland found that loneliness is associated with poor physical and mental health and an unhealthy lifestyle, varying by age but not by gender.

In a recently published study, the researchers tried to trace the number of empirical publications dealing with loneliness as a general concept or social loneliness with an emphasis on older age. They found and reviewed 11,736 articles from 15 countries worldwide.

This is a huge number by all accounts, but the findings do not coincide with the grim reality. For example, loneliness in the context of health is more frequently studied than social isolation. Depression and cardiovascular health are explored routinely concerning loneliness and its consequences, while studies into social welfare are a not-so-close second.

Almost every second article shows a connection between loneliness and medical issues, but there are not enough studies on social isolation and its effects on physical and cognitive health, an individual’s sense of safety, and the quality of human life, and – in a direct link to this article – on the quality of life of the elderly. Still, there is no doubt that loneliness is a major risk factor in old age [9].

As previously explained, the phenomena of loneliness and social isolation manifest especially in the lives of the elderly members of society, who find that loneliness invades every aspect of their lives: physical health – even in the contexts of dentistry, mental health, bouts of anxiety and depression, and issues pertaining to social and family interactions.

There is no doubt that the loneliness experienced by the elderly stems from several key points including the process of retirement from the workplace; the biological process, which includes two prominent factors that isolate the elderly: the deaths of relatives and friends and the prospect of one’s demise, as well as various health issues; cognitive and mental health, as well as the psychogeriatric aspect; and the elderly’s place and role in society from a cultural standpoint as well as a societal one [10].

A study that attempted to pinpoint the root cause of loneliness and its extent among the elderly, named reasons such as the death of a spouse or colleagues, the loss of social roles, and mobility limitations due to illness or physical weakness as catalysts, as they all reduce the ability to maintain social relationships.

Cross-sectional studies show that loneliness is a common experience among the older age group, i.e. individuals aged 85 and over, who are the fastest growing group worldwide [7].  Multiple studies into loneliness among the elderly have shown that at any given time, 40% of them report feeling this way, and 5-7% report an intense or lingering feeling of loneliness. By the age of 80, some 50% of the elderly feel lonely often.

A review of the impact loneliness has on the elderly’s health presents interesting data. A 2006 study that followed 229 men and women aged 60-68 over the period of five years, found an evolutionary link between loneliness and symptoms of depression. A follow-up study in 2010 that looked at 823 elderly people over the period of four years, concluded that lonely elderly people have an increased risk of developing dementia in their later life [11].

The main risk factors for experiencing loneliness include poor health, depression, dire financial circumstances, low social participation, and low social support. Likewise, elders who reside a great distance away from their family or are part of communities that are not close-knit have an increased risk of experiencing loneliness. Other objective factors that greatly contribute to the feeling of loneliness among the elderly are low income, lack of education, and living alone.

The well-being of the elderly in general, and their loneliness in particular, are important topics of discussion in the Western world. The social integration and participation of older people in society are seen as indicators of productive aging, and alleviating loneliness is part of a policy aimed at achieving the goal of "successful" aging.

In the previous chapters, I presented the phenomenon of loneliness, which for decades has been considered the elderly’s nemesis. This issue is familiar to welfare policymakers, as well as to many other decision-makers.  In many countries, the most common way of dealing with this is sending in volunteers, who seek to alleviate loneliness among the elderly by keeping them company. This, however, is only a partial solution and it is largely insufficient, and therefore governments all over have outlined and implemented various programs to deal with loneliness among the elderly. In this section, I will present some of these programs, their successes, and their failures.

A common primary step is to plans seeking to keep the elderly socially active. This is a key component in government policy in nearly every state and is usually part of wider healthcare and welfare policy plans. This is worth noting because often, these policies do not fully encompass all of the elderly’s needs, and various programs that exceed the direct scope of healthcare and welfare must be devised. There are also only a few studies exploring the effectiveness of social and community intervention programs concerning combating solitude in old age.

Studies that have reviewed programs on the subject have been able to ascertain the claim that elderly people who are involved in social interactions feel less lonely and that said interaction does have a positive effect on their health and well-being in general.

The same claim is also presented in a study that reviewed 148 studies in this field and included 308,849 people aged 64 on average. The study found that the risk of mortality decreases by 50% among people with strong social ties.

Still, there is little evidence to suggest that the many plans implemented worldwide have been successful. The conclusion, therefore, is that the nations of the world must pursue a joint effort to formulate plans and subject them to empirical studies; the results of which – be they negative or positive –  should be shared, adopted, and implemented around the world as means of formulating a plan to counter the destructive elements of loneliness.

The difficult data on lone elderly people in Israel, as presented above, highlights the need to devise solutions to this issue. I have presented various programs that are implemented around the world to deal with loneliness among the elderly, and in this chapter, I will present the existing programs in Israel and point out the problems in their implementation.

Israel has many programs on this issue, as part of local initiatives or temporary projects, which try to alleviate loneliness among the elderly. These programs serve tens of thousands of elderly people in Israel – but hundreds of thousands need them. They include day centers, clubs, home visits by volunteers, supporting communities, a volunteer-based home calls program, and more. In this chapter of the essay, I will review most of the programs that try to meet the needs of elderly Israelis and seek to counter the issue of loneliness.

Five major shortcomings stand out: first, the programs are sporadic in their location and outreach and therefore they do not encompass the entire elderly population; second, the initiatives are mostly local and intended for specific target audiences; third, there is administration or authority to direct, centralize, and integrate these activities, mainly because there is no defined objective to them, such as the eradication of loneliness.

A look at two of these major programs illustrates their limited scope: Day centers for the elderly that operate only during the day aim to offer assistance services in day-to-day functions for the disabled elderly who are entitled to nursing care, as determined by the welfare authorities. Services include employment, meals, and social activities. There are currently some 163 such centers that service 18,500 elderly Israelis nationwide.

The Supporting Communities Project seeks to care for the elderly who continue living in their own home but are associated with a community of about 200 elderly households (about 400 people in total). The Ministry of Welfare and Social Affairs sponsors about 250 supporting communities, which are active in 139 municipalities and serve about 70,000 elderly Israelis. 

The purpose of the program is to increase the elderly’s sense of security and meet their social needs. Each community has a "community leader," who knows the members and maintains regular contact with them, and his role is to provide assistance with day-to-day needs and minor repairs in the member’s homes. Social activity is tailored to the needs of community members, and routine and emergency medical services are available, as well.

The author does not doubt that this is one of the classic solutions to the problem of loneliness among the elderly: they remain at home – in their familiar surroundings – and enjoy constant supervision and care by the community leader. They each have a distress button they can use in case of emergency, they have access to a call center and are encouraged to participate in social activities.

The costs are subsidized by the Ministry of Welfare and Social Services, and in communities that are better off socioeconomically, the activities of the supporting community can be expanded into any arena.

However, there is a dramatic gap between the desire demonstrated by dozens of localities, associations, organizations, and formal and informal institutions, to face and defeat the loneliness of Israel's elders, and reality – where only sporadic programs, which are limited in terms of their scope and budget, are available.

The second thing to stand out in this context is the utter lack of cooperation between the dozens of state and municipal bodies tasked with caring for the elderly. Third, it is obvious that so far, no one has bothered to map out the issues that truly bother the elderly – let alone segment them into the reasons, types, or levels of loneliness experienced.

Moreover, there is no pooling of resources or streamlining of processes by which to make essential decisions, and this decentralization prevents optimal care for the individual elder. The fifth thing to stand out is the fact that the personnel resources allocated in an effort to resolve this issue are not utilized properly, as evident by the relatively minor rate of participation in what is supposed to be flagship projects, such as the "supporting community" [7].

The data shows a clear need to deal with the phenomenon, and many nations worldwide, including Israel, have introduced and implemented countless programs to that effect. However, the absence of a clear, mission-oriented, operational concept aimed at fighting loneliness in old age is glaringly obvious.

The need for an integrative approach to this issue was highlighted during the United Nations-led Second World Assembly on Aging, which took place in April 2002 in Madrid, and during which the International Strategy for Action on Aging was put forth to provide practical assistance to policy-makers in dealing with the demographic changes in their societies.

The summit discussed the projected increase in life expectancy, and it explicitly concluded that "only societies that are willing to plan their future will make the most out of one of humanity's great victories in the increase in life expectancy; because this victory birthed an even greater challenge – how to deal with these enormous numbers.”

The Madrid International Plan of Action adopted at the summit offered a bold new agenda for handling the issue of aging in the 21st century. It focused on three priorities: older persons and development; advancing health and well-being into old age; and ensuring enabling and supportive environments [12] – including concerning loneliness and social isolation.

The concept for the fight against loneliness among the elderly – as a basis for creating an adequate plan of action in each country, according to its culture, resources, the socioeconomic background of its population, and unique set of issues – should focus on a clear, precise, feasible, and realistic goal.

The basic objective is devising a central, comprehensive, cohesive resources management scheme for any given society, so as to locate, map, and identify all older members of said society who are struggling with loneliness or social isolation; and use a multidisciplinary approach to diminish the causes and effects of this plight to the minimal level determined by that society.

This sets before us four clear goals for realizing the principle operating concept that will be presented. Realizing these four goals will result in achieving the vision presented in this article: eliminating the phenomenon of loneliness and reducing it into a marginalized element among the elements that prevent older members of society from realizing their potential in later life.

The four goals include placing elders, as individuals, at the heart of the efforts ostensibly pursued on their behalf by the various bodies entrusted with this issue; locating, mapping, and identifying the older individual struggling with loneliness; preparing a personalized "aid package" for each such individual, and determining “care circles” from the state level, through the local authority and community level, to the familial and individual level.

The principles of this operational concept include:

• Circularity: placing the elderly at the center and surrounding them with circles that are part of their daily life. These circles will be conducted under a central authority with a constant flow of information and regular updates on each older individual who has been identified as struggling with loneliness; starting with the familial circle and branching to the community and greater environment, up to the state level.

• Integration: the program’s framework will follow an integrative concept and will be subject to oversight by one government authority.

• Establishing a central administration to oversee the program.

• Knowledge sharing: knowledge and information will flow freely between the components of the operating circles so that community officials will be able to know who the individual elders are and get to know them. For example, they will know which individuals experience loneliness due to mental health issues – data that is currently kept confidential.

• Locating those struggling with social isolation and loneliness as part of an outreach program that will review the status of each of the 900,000 elderly Israelis.

• Pooling resources: concentrating all of the resources appropriated or funneled in favor of this effort – from any ministry or authority participating in its implementation – to streamline the resource allocation process and oversee it meticulously, thus preventing wasting or misusing these resources.

• Intergenerational volunteering and cooperation: engaging lonely elders in activities involving members of the younger generation, both as volunteers for the advancement of the young and as a target for the young to volunteer. 

• Keeping the elderly busy: ensuring elderly individuals’ abilities are utilized for the benefit of the whole, according to the mapping pursued in the initial processes. For example, in Israel, retired engineers can be employed to map buildings that may collapse in case of an earthquake.

• Lifelong learning: engaging the elderly in advanced learning processes in computing and digitization, to ensure they can be part of the contemporary technological world.

• Elderly-oriented healthcare and social services: setting a minimum threshold for the old-age pension in line with minimum wage, mandating the implementation of state-sponsored long-term nursing care insurance, and ensuring accessible, available, affordable, high-quality healthcare services for elderly individuals who are struggling with loneliness, including psychological care for those whose mental health has been compromised by the scourge of loneliness.

• Designating government bodies to deal with specific issues pertaining to countering the phenomenon of loneliness among the elderly.

• Designating “gatekeepers” and “first responders”: this two-pronged measure would establish special teams comprising trained professionals to locate lonely elders according to the data mapped, and intervene in cases where an individual’s wellbeing is in jeopardy.

• Raising public awareness: the entire operational concept must also include a media campaign to reach both the elderly and those around them and alert them to both the risks involved and the available methods of assistance.

The principles of this action plan should be the basis for any national program devised by any nation or society to combat loneliness among the elderly.

This essay sought to review the definition of loneliness in old age and its consequences as I have presented in my research and articles in recent years, as well as outline the existing – inadequate – solutions. However, the guidelines for a national operating concept, as outlined in my articles and research, are only basic ones and must be adapted to the way of life in any given society.

There is an urgent need for a comprehensive, inclusive, resource-rich, and unique program to deal with the phenomenon of loneliness among the elderly and its implications, and not only in Israel.

Basing any future plan on rigid but comprehensive principles, while streamlining the control and management of the said plan, can lead to solutions to the issues at hand. In an aging world, the moment has come for the realization of principles on which billions of human beings were raised: “Do not discard me in my old age; do not forsake me when my strength fails” (Psalm 71:9). These are not casual commandments rather actual words by which to live.