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Qual Life Res (2016) 25:1395–1407

DOI 10.1007/s11136-015-1197-y


Systematic review of interventions addressing social
isolation and depression in aged care clients
Linél Franck1 • Natalie Molyneux1 • Lynne Parkinson1

Accepted: 23 November 2015 / Published online: 8 December 2015 
Springer International Publishing Switzerland 2015

Abstract Conclusions Only one intervention, group-based remi-
Objective A systematic review was undertaken of studies niscence therapy, was reported as successful in reducing
reporting interventions for reducing social isolation and both social isolation and depression in older people within
depression in older people receiving aged care services an urban aged care setting. More research is needed to
(community or residential). explore transferability of interventions across different
Methods Gray literature and relevant electronic databases aged care settings and into rural areas.
were systematically searched for studies published in
English between January 2009 and December 2013. Two Keywords Systematic review  Intervention 
reviewers independently screened studies for selection Social isolation  Depression  Aged care
using predetermined inclusion and exclusion criteria and
independently completed methodological quality review at
study level. Studies of poor methodological quality were Introduction
excluded. Data were extracted at study level by one
reviewer and independently checked by a second reviewer, Social isolation has been identified as an important factor
using a standardized form. The results across studies were in reduced well-being for older people [1, 2]. Social iso-
qualitatively synthesized with outcomes described and lation has previously been inconsistently defined. Con-
summarized at last follow-up. ceptualizations are often unidimensional, focussing either
Results Although the original objective was to review on objective and quantifiable elements such as number of
rural studies, no intervention studies based in rural areas contacts or social interactions [3–6], or subjective elements
met criteria for inclusion in the review, and only urban such as the perception of the quality of social interactions
studies could be reviewed. Of 403 articles, six articles [1]. However, unidimensional, objective definitions of
representing five studies with moderate-to-low risk of bias social isolation can assume that all contacts carry the same
were included for review. All study participants were older emotional and social value [3]. Instead, multidimensional
adults ranging in age from 77 to 86 years. All studies had conceptualizations describe social isolation as a state in
small sample sizes, ranging from 26 to 113 participants. which individuals experience a deficiency of fulfilling and
Three of the five included intervention studies successfully quality relationships, may lack a sense of social belonging,
reduced social isolation; one also successfully reduced and have limited social engagement and often few social
depression. contacts [7]. This definition was adopted in this review,
with the acknowledgement that the ideal number of con-
tacts and the quality of those contacts vary between people,
so one person can have many contacts yet feel socially
& Lynne Parkinson isolated, while another has few contacts yet does not
experience social isolation [7].
Central Queensland University, Building 32, The definition of social isolation must also to be consid-
North Rockhampton, QLD 4701, Australia ered in the context of the conceptually related term,

1396 Qual Life Res (2016) 25:1395–1407

loneliness. Loneliness has also been inconsistently defined, physical and mental health [34]. Research has consistently
making it difficult to distinguish from social isolation. One demonstrated that social isolation can predict increased
way to define loneliness is as an unpleasant emotional morbidity and mortality [6, 35–40], and reduced quality of
experience arising from a person’s perceived discrepancy life, health, and well-being [41–43]. Social isolation has
between their desired and actual relationships [8]. However, also frequently been shown to be associated with mental
given the inconsistency in definitions for social isolation in health concerns, including suicide and depression [44–50],
the literature, and the interchangeable use of social isolation and increased susceptibility to cognitive decline and
and loneliness by service providers and policy makers [9], dementia [51–54]. House [55] found that social isolation
this review follows Cattan et al. [10] in treating social iso- and smoking were comparable in the extent to which they
lation and loneliness as conceptually synonymous. negatively impact health. This finding was supported in a
The little available research indicates significant global meta-analysis by Holt-Lunstad et al. [56], which concluded
variation in prevalence estimates of social isolation in older that the impact of social relationships on mortality risk was
people. European prevalence estimates for social isolation comparable to that of smoking and alcohol consumption,
vary from 5 to 9 % in Germany, the Netherlands, and and greater than that of physical inactivity and obesity.
Denmark; 20 % in Portugal, 35 % in Greece, and 39 % in There is a significant relationship between social isola-
Finland [11]. Prevalence estimates for the UK (UK) and tion and depression [18, 56, 57]. Social isolation is an
Australia are similar, with 7–17 % of older people often independent risk factor for depressive symptoms [46, 58],
experiencing social isolation, and up to 31 % of older and mortality risk associated with loneliness is partially
people sometimes experiencing social isolation [12–15]. explained by health outcomes such as depression [39].
A Malaysian study found that 50 % of respondents were at However, Stek et al. [60] found that perceived loneliness or
risk of social isolation [16]. Although the available depression did not independently predict mortality risk,
prevalence estimates of social isolation vary, the majority while perceived loneliness and depression in combination
of studies indicate that social isolation is relatively com- increased mortality risk 2.1 times [59]. The effects of the
mon in older people. two attributes are difficult to separate, and the relationship
Studies suggest that prevalence and risk of social iso- between loneliness and depressive symptoms is not
lation are higher for older adults living in residential aged attributable to demographic variables, dispositional nega-
care settings than for those living in private dwellings tivity, stress, social support, or objective social isolation
within the community [17–22]. For example, studies in [39]. Recent research has found that depressive symptoms
Sweden and Norway have found that approximately 56 % in aged residential care clients could be decreased over
of nursing home residents are lonely [23, 24]. Although time by increasing meaningful social engagement activities
some research suggests these high estimates may be due to [60].
premature entry to residential care as a result of social There is a need to identify effective interventions to
isolation prior to admission [18, 25–27], Scocco et al. [28] address social isolation and depression in older people,
suggest that factors in residential aged care settings given the relatively high prevalence and the known health
aggravate and perpetuate social isolation. impacts [61]. Previous systematic reviews have agreed that
Some studies have found that living in rural areas can the poor methodological quality of intervention studies
increase the risk of social isolation in older people and may impedes definitive conclusions about intervention effec-
present a greater health vulnerability to the socially isolated tiveness [3, 10, 62]. Despite the limitations found in the
[29]. A higher prevalence of social isolation was found in studies available to these reviews, program components
Finnish rural (45 %) compared to urban (40 %) older associated with successful interventions have been identi-
people [19]. In China, 78 % of 5652 rural older people fied. These include high-quality training and support of
reported moderate-to-severe levels of loneliness [30]. An staff [63], and involving older people in the planning,
increased risk of social isolation in rural older adults was implementation, and evaluation of interventions utilitizing
also found in Australia [22]. The emerging evidence for community resources [3, 10, 62]. In addition, Cattan et al.
increased social isolation in rural areas has relevance to the [10] and Dickens et al. [3] found that group-oriented edu-
Australian context where nearly 30 % of the general pop- cation or social support programs are most effective,
ulation live in rural areas and older people tend to move especially when based on a theoretical framework. Previ-
from urban to rural areas to retire [31–33]. However, there ous systematic reviews of interventions addressing social
has only been limited research exploring rural living as a isolation expressed the need for development of the evi-
risk factor for social isolation in older people. dence base by high-quality evaluation of interventions.
The relatively high prevalence estimates for social iso- This systematic review update focuses particularly on
lation are concerning, given that social isolation is studies from the 5 years since the previous similar review
acknowledged as having a detrimental effect on both to answer the question: What effective interventions exist

Qual Life Res (2016) 25:1395–1407 1397

that address social isolation and depression in aged care participants were mostly under the age of 60 years
clients living in rural settings? were excluded.
• Studies involving participants receiving aged care
services (community or residential) were included.
Method Aged care clients are a particularly disadvantaged group
with high levels of depression and social isolation.
The preferred reporting items for systematic reviews and Studies where participants were in retirement commu-
meta-analyses (PRISMA) guidelines were followed in nities were excluded, as this is a very different group
reporting this systematic review [64]. from aged care clients, in terms of physical functioning,
access to services, and social opportunities.
Search strategy • Only intervention studies were included, with no design
The search strategy was customized to each database using • Although studies conducted in rural areas were pre-
database-specific Thesaurus terms and subject headings. ferred, the limited rural-based research meant that
Keywords were generated from the domains of social studies conducted in an urban setting were also
isolation, loneliness, depression, older adults, community included.
aged care, residential aged care, rural, regional, and inter-
vention. A computerized search of publications between
Methodological quality review
January 2009 and December 2013 was conducted in the
electronic databases of MEDLINE, CINAHL with Full
Independent methodological quality review was completed
Text, SocINDEX with Full Text, Health Source: Nursing/
at study level by two reviewers using the Downs and Black
Academic Edition, PsycARTICLES, PsycINFO, Academic
[65] checklist for methodological quality assessment of
Search Complete, and the Psychology and Behavioral
randomized and nonrandomized studies of healthcare
Sciences Collection. Gray literature searches included
interventions. This checklist includes items assessing
Google, government health and aging websites, and aged
quality of reporting, internal validity, and external validity
care organization websites. All searches were conducted in
[65]. Items 1–26 on this checklist were considered in the
July 2014.
quality review. A high-quality study was quantitatively
considered as having low risk of bias with a score of 19 or
Study selection
higher on the 26 items considered. A low-quality study was
quantitatively considered as having a high risk of bias with
Two researchers independently screened the titles,
a score of 13 or below. This review excluded all low-
abstracts, and full text of all retrieved articles with a third
quality studies in order to increase confidence in the find-
researcher being consulted where there was lack of con-
ings of the reviewed interventions. Where there was a lack
sensus. Studies were selected using the following inclusion
of consensus, reviewers came to a mutual agreement
through revision of evidence supporting or refuting items
• Articles published as full reports in English were in the Downs and Black [65] checklist.
included. Letters, abstracts, books, conference proceed-
ings, press releases, newsletters, posters, informal Data extraction
internet articles, presentations, brochures, and reviews
were excluded. Data were extracted at study level by one reviewer and
• The study must have been published between January independently checked by a second reviewer, using a
01, 2009, and December 31, 2013. This timeframe standardized form that included items related to publication
encompasses 5 years from the most recent similar details, study design, setting, participant characteristics,
review before this review was undertaken. intervention characteristics, and results significant to the
• No exclusions were made on the basis of country of review question. Where there was not consensus, a third
origin. reviewer resolved disagreements.
• Only studies reporting an intervention that addressed
the outcomes of social isolation or loneliness, or the Study synthesis
combination of depression with social isolation or
loneliness were included. The results across studies were qualitatively synthesized
• Studies involving participants who were mostly aged with outcomes described and summarized at last follow-up
60 years and over were included. Studies where where data were provided. A meta-analysis was not

1398 Qual Life Res (2016) 25:1395–1407

undertaken given the heterogeneity of methods, measures, Study characteristics
and resultant data.
The characteristics of the included studies are detailed in
Table 1. Each study was conducted in a different country;
Results one from Australia [69, 70], one from the USA [68], one
from the UK [67], one from Hong Kong [71], and one from
Study selection Taiwan [66]. Studies included two experimental designs
[67, 695]: one quasi-experimental pre- and post-test with
Database and gray literature searches retrieved 828 articles. control group design [67], and two quasi-experimental pre-
Of these, 425 were duplicates, resulting in 403 articles and post-test design with no control groups [67, 69, 70].
screened by titles and abstracts, of which 345 did not meet Three of the five studies had a 3-month follow-up [66, 67,
the inclusion criteria. Full texts were retrieved for the 69, 70], with the remaining two following up at 8 weeks
remaining 58 articles of which a further 36 did not meet the [71] and 10 weeks [68].
inclusion criteria and were excluded. Methodological All participants were older adults ranging in age from 77
quality assessment was conducted on the remaining 22 to 86 years. One study had a near equal ratio of male to
articles, which resulted in the exclusion of a further 16 female participants [67], and another had an all-male
articles based on a high risk of bias. Only six articles were sample [66]. The participants in the remaining three studies
identified as having moderate-to-low risk of bias and were were predominantly female with males compromising
retained for qualitative synthesis. These six articles repre- 11 % [68], 15 % [71], and 29 % [69, 70] of the sample
sent five discrete studies. This screening process can be size. All interventions were conducted in an urban resi-
seen in Fig. 1, including the reasons for exclusion of 36 of dential aged care facility (RACF) setting.
the 58 full-text articles. Three of the interventions were group-based activities
[66, 67, 71], one was an individual activity [69, 70], and
Quality assessment one was a duo activity [68]. Chiang et al. [66] conducted
eight group-based reminiscence therapy interventions
Of the five discrete studies, only one was rated as high facilitated over a period of 2 months by a postgraduate
quality, [66] with the remainder being of moderate quality student and co-leader who received didactic training and a
[67–71]. Across all studies, the participants were not rep- reminiscence group therapy manual to complement their
resentative of the entire recruitment population. One study existing experience in the area. Gleibs et al. [67] imple-
had not recruited participants over the same time period mented gender-based social group interventions facilitated
[69, 70], and reviewers were unable to determine whether fortnightly by a member of the RACF staff who received
participants were recruited from the same population in training in delivery of the intervention with support from
two studies [67, 69, 70]. No studies attempted to conceal the training coordinator at the facility. Tse [71] created an
randomized assignment to intervention or to blind either indoor gardening program with group and individual par-
subjects or those measuring intervention outcomes. It was ticipation aspects. Once a week, participants were taught
unclear whether participants were randomized to the by a research team how to carry out gardening activities,
intervention group by appropriate methods in three studies but were responsible for their own plants during the
[67–70]. Only two of the five studies conducted interven- 8 weeks, finishing by sharing experiences and planting
tions using staff and facilities representative of the treat- diaries as a group [71]. Kahlbaugh et al. [68] implemented
ment most patients receive [67, 69, 70]. Compliance to a duo activity intervention allowing aged care clients to
interventions could not be determined in two studies [67, play a Nintendo Wii game of their choice for 1 h a week
68]. While most studies adjusted for varying follow-up in the company of an undergraduate research assistant.
lengths or held the interval between intervention and out- Travers and Bartlett [69, 70] broadcast a radio program,
come constant, this was unable to be determined in one which individuals listened to for 1 h daily over 3 months,
study [69, 70]. Another two studies did not take into requiring only assistance from RACF staff where technical
account loss of participants to follow-up [66, 71], one of difficulties arose. This study was the only one to comment
which also did not sufficiently describe characteristics of on cost-effectiveness of the intervention, however, only to
subjects lost to follow-up [71]. Confounders were not the extent of labeling the intervention as being inexpensive
adjusted for in two of the five studies [69–71]. No studies [69, 70]. Other studies provided no details about the cost of
measured or reported the adverse consequences of inter- intervention implementation.
ventions. All studies had small sample sizes ranging from Outcome measures were similar across studies, with
26 [68] to 113 [70] participants, with two studies reporting some measuring more outcomes than others (see Table 2).
a high attrition rate ranging of 26 % [66] and 30 % [69]. Gleibs et al. [67] measured social identification [72],

Qual Life Res (2016) 25:1395–1407 1399

Arcles idenfied through Addional arcles idenfied

database searching through other sources
(n = 752) (n = 76)

Arcles screened aer duplicates
(n = 403)

Arcles excluded: did not meet inclusion criteria based on screening of tle and abstract
(n = 345)

Full-text arcles excluded
(n = 36)
Full-text arcles . 12 arcles were not intervenons
assessed for eligibility . 6 arcles were not set in community or
(n =58) residenal aged care sengs
. 6 arcles used parcipants younger than 60

. 7 arcles were not full reports as per criteria
. 5 arcles did not measure outcomes of social
isolaon or loneliness

Methodological quality High risk of bias
assessment arcles excluded
(n =22) (n = 16)

Arcles included in
qualitave synthesis
(n = 6)

Fig. 1 Flow diagram detailing data screening process

personal identity strength [73, 74], well-being [75], anxiety Main findings
and depression [76], and cognitive ability [77]. Chiang
et al. [66] measured the outcomes of depression [78], The main results of the five included studies can be found
loneliness [79], and psychological well-being [80]. Kahl- in Table 2, summarized at final follow-up across outcome
baugh et al. [68] measured physical activity [81], loneliness domains. Chiang et al. [66] concluded that reminiscence
[79], mood [82], life satisfaction [83], and health [84] as therapy reduced feelings of loneliness and depression while
outcomes. Tse [71] measured the outcomes of loneliness creating a sense of accomplishment in participants with
[79], life satisfaction [85], physical activity [86], and social improved psychological well-being. Gleibs et al. [67]
network situation [87]. Travers and Bartlett [69, 70] mea- found a gender effect where the social group-based inter-
sured depression [88], quality of life [89], loneliness using vention benefitted males by significantly reducing depres-
a single-item question [90], and social isolation using two sion and anxiety while increasing a sense of social
questions developed by the authors [69]. identification. Females reported little change over time in

Table 1 Characteristics of intervention studies to reduce social isolation and depression in aged care clients

Study Chiang [66] Gleibs [67] Kahlbaugh [68] Tse [71] Travers [69, 70]

Intervention type Reminiscence therapy Gender-based social clubs Nintendo Wii games Indoor gardening program Radio program
Country Taiwan UK USA Hong Kong Australia
Publication date 2010 2011 2011 2010 2010, 2011
Study design Experimental Quasi-experimental pre- and Experimental Quasi-experimental pre- and Quasi-experimental pre- and
post-test without control post-test with control groups post-test without control
group group
Convenience sample (responded Convenience sample Convenience sample Convenience sample (responded Convenience sample (responded
to advertisement) (responded to invitation) (responded to advertisement) to advertisement) to advertisement)
Follow-up at 3 months Follow-up at 3 months Follow-up at 10 weeks Follow-up at 8 weeks Follow-up at 3 months
Participant Urban residential care Urban residential care Urban residential care Urban residential care Urban residential care and in the
characteristics community
(setting, sample
inclusion criteria,
Initial N = 130 Initial N = 30 Initial N = 36 Initial N = 53 Carers: N = 24
Post-attrition N = 92 (attrition Post-attrition N = 26 (attrition Post-attrition N = 35 (attrition Nil attrition reported Participants: Initial N = 154
rate: 29 %) rate: 13 %) rate: 3 %) Females: n = 32 Post-attrition N = 113
Females: n = 14 Males: n = 4 (Attrition rate: 27 %)
Males: n = 12 Mean age: 82 years (SD 9.8) Females: N = 80
Mean age: 86.06 years Males: N = 33
(SD 7.94) Mean age: 79.9 (SD 8.9)
EG: Initial n = 65 EG: n = 16 EG: n = 26
Post-attrition n = 45 Mean age: 85 (SD 7.8) Females: n = 25
Females: n = 0 CG 2: n = 7 Males: n = 1
Males: n = 45 Mean age: 84 (SD 7.0) Mean age: 85.23 (SD 5.2)
Mean age: 77.42 years
(SD 3.71)
CG: Initial n = 65 CG 1: CG: n = 27
Post-attrition n = 47 Initial n = 13 Females: n = 20
Females: n = 0 Post-attrition n = 12 Males: n = 7
Males: n = 47 Mean age: 78 (SD 12.5) Mean age: 83.00 (SD 7.85)
Mean age: 77.06 years
(SD 4.23)
Qual Life Res (2016) 25:1395–1407
Table 1 continued
Study Chiang [66] Gleibs [67] Kahlbaugh [68] Tse [71] Travers [69, 70]

Inclusion: conscious; able to Unable to determine inclusion Unable to determine inclusion Inclusion: aged 60 years and Inclusion: participants aged 60 years
speak Taiwanese or Mandarin; and exclusion criteria and exclusion criteria over; able to speak Cantonese; or over; capable of answering
aged 65 years and over; MMSE MMSE score of 6 or more questionnaires; agreed to listen to
score over 20 the radio program for an hour a day
for 3 months; carers and care staff
of participants who occasionally
listened to the radio program
Exclusion: evidence of Exclusion: bed-bound; history Exclusion: participants who
Qual Life Res (2016) 25:1395–1407

significant cognitive of mental disorders; history of were profoundly deaf; MMSE
impairment allergy to pollen, seed, score of less than 14
fertilizer, and plants
Intervention Eight weeks of 90-min group Over 3 months, fortnightly Weekly hour-long sessions playing Over 8 weeks, gardening activities Participants listened to the radio
reminiscence therapy sessions gender-based club meetings a Wii game of choice for and education were facilitated program for an hour a day over
facilitated weekly by a and activities were facilitated 10 weeks. A research assistant once a week. Each participant was 3 months and recorded listening
Master’s degree student and by a staff member of the care was assigned to the same responsible for their own planting. activity in a daily diary. Music
trained co-leader facility of the same gender as participant, and visited them at They received a planting diary to and serials from 1920 to 1950
the group each session to play Nintendo Wii be shared with others were broadcasted
Control group Waiting list CG met to complete CG 1: Weekly hour-long CG: Older people in other
assessment instruments during sessions of watching preferred nursing homes received usual
the same weeks as the EG TV programs for 10 weeks. A care with no indoor gardening
(pretest, post-test, and 3-month research assistant was program participation, but
follow-up) assigned to the same completed outcome measures
participant and visited them at baseline and 8 weeks
for each session
CG 2: served as a baseline and was
not visited by a research assistant
Outcome measures Loneliness: Revised University Social Identity: Two items from Loneliness: UCLA Loneliness Loneliness: UCLA Loneliness Social Isolation: two questions
of California Los Angeles a Social Identification Scale Scale V3 [79] Scale [79] developed by the authors [69]
Loneliness Scale (RULS-V3) [68] Personal identity Mood: Positive and Negative Life Satisfaction: Life Loneliness: single-question item
[79] strength: Five items adapted Affect Scale (PANAS) [82] Satisfaction Index-A [85] adapted from Victor et al. [90]
Depression: Center for from a Self-Clarity Scale [73]
and the Personal Identity Physical activity: Adapted Social network: Lubben Social Depression: Geriatric Depression
Epidemiological Studies Weekly Physical Activity Network Scale (LSNS) [87] Scale-5 (GDS-5) [88]
Depression Scale (CES-D) Strength Scale [74]
Scale [81] Physical Activity: Modified Quality of Life: The Quality of
[78] Cognitive Ability:
Barthel Index [86] Life Alzheimer’s Disease Scale
Psychological Well-being: Addenbrooke’s Cognitive (QOL-AD) and the Alzheimer’s
Symptoms Checklist-90-R Examination Revised (ACE- Disease Nursing Home Scale
(SCL = 90-R) [80] R) [78] (QOL-AD-NH) [89]
Life Satisfaction: Single item
Anxiety and Depression:
Hospital Anxiety and
Depression Scale (HADS)

Table 1 continued

Study Chiang [66] Gleibs [67] Kahlbaugh [68] Tse [71] Travers [69, 70]

Main findings Loneliness: significant Social identity: significantly Loneliness: EG had lower Loneliness: significant Loneliness: NSD (p = 0.2)
difference between CG and increased over time for males loneliness than CG 1 at post- reduction for EG compared to Depression: significant
EG on follow-up test (p = 0.09), NSD for females test (F (2,30) = 6.24, CG (p \ 0.001) improvement (t (112) = 2.99,
(z = -27.26, p \ 0.0001, (p = 0.44) p \ 0.005) Life Satisfaction: significant p = 0.003)
z = -22.75, p \ 0.0001), Personal identity: significantly Mood: NSD (exact p value not reduction for EG compared to
with EG showing Quality of life: significant
increased over time for both provided) CG (p \ 0.001) improvement
improvement from moderate- males (p = 0.08) and females
to-mild loneliness Physical activity: NSD (exact Social Network: significant (t(112) = -4.19, p \ 0.000)
(p = 0.04) p value not provided) reduction for EG compared to
Depression: significant Participant and Carer Interviews:
Cognitive Ability: no change CG (p \ 0.001) radio program positively
difference between CG and in either gender group, all
EG on post-test and follow-up Physical activity: influenced well-being, morale,
F \ 0.50 NSD (p = 0.06) and behavior of older listeners.
(z = -7.09, p \ 0.0001;
z = -7.82, p \ 0.0001), with Well-being: life satisfaction Relaxation was most reported
EG showing improvement in increased significantly for benefit. Listeners with dementia
depressive symptoms males over time (p = 0.09), seemed to receive greatest
NSD for females (p = 0.42) benefit. Friendliness and quality
Psychological well-being: of program highly rated
significant difference between Depression: decreased
CG and EG on follow-up test significantly over time for
(z = -10.25, p \ 0.0001, males (p = 0.03), NSD for
z = -10.63, p \ 0.0001), females (p = 0.62)
with EG showing improved Anxiety: significantly decreased
psychological well-being over time for males
(p = 0.09), NSD for females
(p = 0.39)
Recommendations Possible facilitators of Authors cautioned the potential of Participants report general Positives: Low cost; flexible;
and additional improvement include the in- and out-group formations. impressions of a very positive geographically wide-ranging;
intervention group processes of sharing, Program otherwise was experience with feelings of reduced agitation in patients
information interacting, feedback, and associated with facilitation of a pleasure, happiness, Suggested Improvements: less
praise, which encourage sense of belonging, enjoyment, responsibility and engagement chat shows; less heavy
cohesion, friendship, personal and shared positive emotional in social activity with classical music and opera;
understanding of each other, a experiences increased levels of physical music over a greater range of
sense of belonging to a group, Although the research assistants activity eras; international music; old
and acceptance by a group were socially responsive to Does not require previous radio serials; stories about past
Facilitators of reminiscence participants in both the TV and gardening experience famous people
therapy were also highly trained Wii groups, actively engaging in Barriers: problems with
in this evidence-based therapy Wii activities may have reception and interference
There, was however, facilitated relationships between with radio signal during
approximately a 30 % attrition the participant and research shared signal use prior to
rate with common reasons being assistant in a way that passively obtaining a dedicated line for
scheduling clashes, health watching TV does not the radio program; faulty leads
problems or hospitalization, and on some radios solved by
a disparity in expectations of the replacing leads with batteries
activity and actual experience of
the activity
MMSE mini-mental state examination, EG experimental group, CG control group, NSD no significant difference, SD standard deviation
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Qual Life Res (2016) 25:1395–1407 1403

Table 2 Summary of main findings by outcomes at final follow-up, for included studies
Study Chiang [66] Gleibs [67] Kahlbaugh [68] Tse [71] Travers [69, 70]

Intervention Reminiscence therapy Gender-based Playing Wii Indoor Gardening Radio Program
Social Clubs Program
Groups EG versus CG Male versus EG versus two CGs EG versus CG Pretest and post-
female test
comparison, no
Time frame 3 months 3 months 10 weeks 8 weeks 3 months
Social Significant difference between NM Wii group had lower Significant increases in No change in
isolation CG and EG on follow-up test loneliness at post-test, life satisfaction, loneliness
(z = -27.26, p \ 0.0001, TV group higher socialization, and (z = -1.27,
z = -22.75, p \ 0.0001), loneliness post-test reductions in loneliness p = 0.2)
with EG showing (F (2,30) = 6.24, for experimental groups
improvement from moderate- p \ 0.005) (p \ 0.05)
to-mild loneliness
Depression Significant difference between Decreased NM NM Decreased
CG and EG on post-test and significantly over significantly
follow-up (z = -7.09, time for males (t(112) = 2.99,
p \ 0.0001; z = -7.82, (p = 0.03), NSD p = 0.003)
p \ 0.0001), with EG for females
showing improvement in (p = 0.62)
depressive symptoms
EG experimental group, CG control group, NM not measured

depression and anxiety, but did report increased personal measure this outcome, despite having the objective to
identity strength post-intervention, similar to the males. reduce social isolation [67]. The remaining three studies
They found no change in cognitive function for either reported reducing social isolation [66, 68, 71]. Two of
group over time [67]. Kahlbaugh et al. [68] found that these three studies, however, found no significant reduction
playing Nintendo Wii improves participant well-being, in depression [9, 71]. The study by Chiang [66] found that
social connection, and enjoyment, as shown through a reminiscence therapy intervention successfully reduced
decreased loneliness and increased likelihood of positive both social isolation and depression. Therefore, well-
mood. Tse [71] concluded that an indoor gardening pro- trained staff facilitating group-based activities that offer
gram might decrease loneliness while improving social- support and social interaction through sharing and the
ization and life satisfaction, irrespective of factors such as establishment of common ground appear to be the most
age, finances, education, and any level of prior gardening successful interventions addressing social isolation and
experience. Participants commented on feelings of plea- depression in RACF clients. A qualitative summary of
sure, happiness, responsibility, increased physical activity, results by outcome domains can be found in Table 3.
and the positive experience of engagement in social
activity. Travers and Bartlett [69, 70] found that listening
to a radio program did not change levels of loneliness in Discussion
participants, but did improve depressive symptoms and
quality of life. RACF carers perceived the radio program as This systematic review aimed to identify effective inter-
high quality and friendly, and felt it had a positive influ- ventions for reducing social isolation and depression in
ence on participants’ morale, well-being, relaxation, and aged care clients, with a particular interest in interventions
behavior [69, 70]. in rural areas. However, none of the retrieved studies
conducted in a rural context were of sufficient method-
Study synthesis ological quality for inclusion in this review, so this review
could only consider interventions set in urban areas.
Social isolation and depression are the main outcomes of Of the five identified interventions to address social
interest to this review. Of the five included studies, one isolation, two cannot be recommended; one study did not
found no significant difference in social isolation pre- to measure social isolation as an outcome [67], and one found
post-intervention [69, 70], and one did not specifically no significant improvement in social isolation [69, 70]. The

1404 Qual Life Res (2016) 25:1395–1407

Table 3 Qualitative summary of main results by measured outcomes, for included studies
Study Chiang [66] Gleibs [67] Kahlbaugh [68] Tse [71] Travers [69, 70]

Intervention Reminiscence therapy Gender-based social clubs Playing Nintendo Wii Indoor gardening program Radio program
Follow-up period 3 months 3 months 10 weeks 8 weeks 3 months
Social isolation SE NM SE SE NSD
Depression SE Males: SE NM NM SE
Females: NSD
SE significant effect, NSD not significantly different, NM not measured

remaining three interventions all significantly reduced definition of social isolation and considered related con-
social isolation; however, depression was not measured as cepts in the search strategy to capture relevant intervention
an outcome by two studies [68, 71]. Reminiscence therapy studies.
was the only intervention which significantly reduced both Although many studies that may have reported viable
social isolation and depression and can be considered a interventions were excluded due to poor quality
successful intervention addressing both social isolation and throughout the methodological quality review process, the
depression in the RACF setting [66]. Based on this study, inclusion of only moderate-to-high-quality studies
the most benefit seemed to be derived from programs that improves the confidence with which conclusions can be
involved well-trained staff facilitating group-based social made in this review. Generalizability of results across
activity or support where social interaction was maximized countries is, however, difficult, given that aged care
through sharing stories and fostering a shared common organizations and their definition of standard care may
ground on which to base interaction. differ across countries.
These results are similar to previous systematic reviews, Future research should consider the transferability of the
supporting the findings that well-trained staff facilitating identified successful interventions to other aged care (such
social activity or support in group-based formats where as community-based care) and geographical settings.
older people are active participants in the program are During implementation and evaluation of interventions, it
common characteristics of effective interventions [3, 10, is important that information about costs, sustainability,
63]. Where previous systematic reviews were inconclusive, long-term effectiveness, staff training, barriers, and facili-
this review found three successful interventions of mod- tators be detailed, to inform service providers about
erate-to-high methodological quality in the RACF setting effective implementation and transferability of programs to
[66, 68, 71], all of which reduced social isolation, and one other situations. It is essential that future research includes
which also reduced depression [66]. adequate evaluation of intervention effects, with appro-
This systematic review builds on the evidence base priate experimental design and reliable measures to maxi-
established by previous reviews by retrieving data from mize confidence in research findings. Additionally, there is
studies of any design, published from 2009 to 2013, by a need to establish clear and consistent definitions of terms
considering a wider range of outcomes consistent with a such as social isolation, loneliness, social connectedness,
multidimensional definition of social isolation, and by social integration and so on, including clear distinction
including the context of the risk factors for aged care set- between these terms. This clarification would improve
tings [3, 10, 63]. The use of a 5-year date range enables measurement of these concepts, and consequently the
identification of interventions published since the most design of interventions, comparability across studies, and
recent identified systematic review. Reviewing only studies then potential transferability.
published in English may have introduced bias [91]; In summary, this systematic review identified one
however, pragmatic limitations necessitated this decision. intervention, reminiscence therapy, that successfully
Through the use of a comprehensive search strategy, tai- addressed both social isolation and depression in urban
lored to each individual database, and by enforcing no RACF clients [66]. Two interventions successfully reduced
limitation on study design, the likelihood of retrieving social isolation, but not depression [68, 71]. The effec-
potential intervention studies was increased. The incon- tiveness or feasibility of these interventions in the rural
sistent definition of social isolation and its relationship to context is yet to be established; it remains unclear how
loneliness remains a barrier to research in this domain and interventions from urban settings would need to be modi-
has implications for the identification and interpretation of fied for rural settings. This is an important gap for future
interventions. This review used a theoretically supported research.

Qual Life Res (2016) 25:1395–1407 1405

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