Having given thanks for deliverance from a horrid shipwreck on an apparently deserted island, Daniel Defoe’s Robinson Crusoe suddenly comes face to face with that old cliché about being careful what you wish for.
“I had a dismal prospect of my condition,” Crusoe reflects on his abrupt confrontation with loneliness, “for … I had great reason to consider it as a determination of Heaven, that in this desolate place, and in this desolate manner, I should end my life.”
 Bill Thomas
If Bill Thomas had his way, every long term care provider in the country would have that passage memorized. He wants providers to see their residents in much the same way that Defoe makes his readers see Crusoe: marooned in a strange place and wishing they, too, could simply have been swallowed by the waves like their companions.
“What we find is that loneliness is the pain that people feel when they want but can’t have companionship,” says Thomas, an MD from Harvard who is generally considered one of the leading philosophers of person-centered care.

The Paradox Of Long Term Care Loneliness

Thomas’ disquisitions on loneliness aren’t just literary. He and many other scientist-advocates are convinced that loneliness is a clear, present—and growing—danger in long term care.
“Loneliness kills,” he says. “Human beings, despite all of our high-minded rhetoric, are social animals. We are made to live together. If you see a honeybee that has lost track of the hive or the ant that has lost track of the anthill—they’re doomed. While it might not be quite as dramatic as those cases, a human being who is cut off from society is going to suffer terribly.”
The problem is, in a long term care setting, residents are—by definition—not marooned. They are literally surrounded by their peers, and given often round-the-clock care by hard-working people who really, truly want the best for them.
And yet, a May 2011 Norwegian study of skilled nursing centers found that 56 percent of their patients felt lonely.
Closer to home, experts estimate that 35 percent of residents in American long term care centers suffer from clinical depression.
“The problem,” says Judah Ronch, dean of the Erickson School at UMBC (University of Maryland Baltimore County), is that “loneliness is different than being alone. As an industry, we sort of have looked at the tendency to be alone as a kind of pathology. The worst thing we can do is enforce socialization on [residents], because they find it very stressful.
“What’s sad is that so much of the interaction is so structured—it’s usually through the [facility’s activities] programming—and because mobility is so limited … whatever natural tendencies and abilities the person would come in with quickly fall into disuse,” Ronch says. “So the person isn’t able to exercise the major motivational point of social integration, which is that you go and do something that’s interesting to you, in something that you care about, with people that are interesting to you.”Judah Ronch
Thomas agrees. “One of the reasons we have an epidemic of loneliness in long term care,” he says, “is we’ve concentrated our efforts around measurable data points. If I walk into a long term care center and I see this huge calendar on the wall and see all of these activities, I think, ‘Well, there’s no loneliness here.’"
Even Defoe’s Crusoe knew something about that.
When he finds a human footprint in the sand after two years alone on “his” island, Crusoe is unpleasantly surprised: “for I, whose only affliction was that I seemed banished from human society … I say, that I should now tremble at the very apprehensions of seeing a man, and was ready to sink into the ground at but the shadow or silent appearance of a man having set his foot in the island.”
The answer for an increasing number of experts is person-centered care. “We know that relationships can come [with] risks, especially as people live with dementia. Senior living can be a great prescription for loneliness,” says Juliet Holt Klinger, vice president of senior care for Brookdale Senior Living, Brentwood, Tenn. “If we’re doing person-centered care the right way, then it’s all going to be relationship-based.” The decades of research have begun to pile up, and they make it clear that loneliness is dangerous. The good news is, there may be a cure for it.

The Search For The Cure

Modern technology, of course, may provide an answer. And, indeed, social media applications, iPods, tablets, and other miracles of the tech age are literally opening new worlds in nursing homes. 
“You get people that are 92—totally checked out, you would think,” says Jack York, founder of It’s Never 2 Late, a tech company that specializes in helping seniors connect (or reconnect) with the world. 
“All of a sudden you go on to Google Earth and show them the farm they grew up on 70 years ago, and they just appear. Part of it is the technology, but part of it is just helping them connect with things that we just take for granted.”
For all that, it’s probably not time to brace up for the Rise of the Machines, whatever the futurists say.
“If your standards of care are person-centered, then the expectation is that the [staff] will build relationships with the residents and also pay attention to the other relationships in their lives,” Holt Klinger says. “We’ve really found the technology just a remarkable way to do that.”
That doesn’t mean it’s the only way, experts say. Technology is a terrific tool—but merely that.
“You always have to keep in mind that you have to meet the person where they are,” says Cameo Rogers, the life enrichment coordinator for Vetter Health Services, Omaha, Neb.
“You want to make sure that you’re always very positive and encouraging and that you treat the person with the utmost dignity and respect.”
Cameo Rogers
Vetter, like Brookdale, has adopted It’s Never 2 Late and other technologies into its care. 
But the gadgets are designed, like Crusoe’s Friday, to serve the residents, and not the other way around.

Get To Know That Person

“The first thing that we need to do is get to know that person,” Rogers says. “We do a life’s story upon admission. Get to know who that person is, where they came from, what’s important to them.”
There are a number of assessment tools available to providers, but Rogers says that the key thing is to be able to adapt to how families are responding to the questions they’re being asked.
“You can’t go in the same way to every patient and expect the same results,” she says. “Some people really do well with a checklist and clipboard, but others don’t.”

Those few extra minutes can make a universe of difference. Brookdale’s Holt Klinger likes to tell the story about one of their residents, who was living in a dementia care center and was definitely not happy to be there.

“And the program coordinator read his well-filled-out social history and discovered where he went to college,” Holt Klinger says. “She looked up the fight song on It’s Never 2 Late.”

While the coordinator played the fight song from the old alma mater, she noticed that the man was keeping time, using a reach tool as a drum stick, Holt Klinger says.
"So she got another reach tool and then pulled up the drum app, and they would drum to the fight song,” Holt Klinger says. 
When the man’s daughter heard how calm her father became upon being able to tap out his school’s fight song, the memory bank opened, Holt Klinger says.  
“My God,” Holt Klinger quotes the woman as saying, “it brings back this memory that when we were kids my father would come home and pour himself a Scotch and go bang on the drum kit for about half an hour.”

Background: The Source Of Inspiration

The point is, the technology helped. But it wouldn’t have worked without a thorough background of the man, Holt Klinger says.
“You’re not necessarily going to have a metric that shows you that it’s helped you increase move-ins … this is strictly an investment in quality of life,” she says.
The point, experts say, is to let the patient choose—truly choose—the path he or she takes in his or her care.
“Studies were done as early as 1976,” UMBC’s Ronch says. “When you give nursing home residents a choice—even if it’s not a wide range of choices—they do better than when the staff say, ‘Here’s what we’ve picked out for you, we know better.’”

That means recognizing one’s own limits as a provider, experts say. Yes, budgets are tight, so providers have to think creatively about what social activities they offer.

Go To The Source

“The first thing you would ask is, ‘How would grandmother spend her time, with whom and how much did she like it?’” Ronch says. “And then you’d say, ‘Here are some of things we do that approximate that, and we’d like to have her try it.’
“You notice that I haven’t asked about her diagnosis?”
Ronch cites the case of a nursing home he consulted a decade or so ago. With a few bucks, the home redesigned its dining room so that it had three decors, from ultra-casual snack bar to formal dining. The decorations weren’t elaborate—mostly just a change in paint—but the effect was dramatic, Ronch says.
“Just knowing that they had those choices was very motivational, and I think they got better nutritional compliance as well,” Ronch says.

Learned Helplessness

When residents feel they’re being deprived of choice, their social skills begin to atrophy, experts say. It happens physically, too: Vetter’s Rogers calls it “learned helplessness.”
“You lose the ability to move your right hand, you lose the ability to crochet, you lose the ability to feed yourself,” Rogers says. “What happens is they start to lose that sense of control over their entire lives, and so they ask people to do things for them.”
That, in turn, only increases feelings of loneliness—even in a crowded room: People become spectators to their own lives, experts say.
“What we really try to focus on is what can they do? What are their possibilities?” Rogers says. “You want to make sure that you’re always very positive and encouraging and that you treat the person with the utmost dignity and respect. If the person has not been assisting themselves with dining for a long time … you don’t just expect that person to do that overnight. You look at where they are at and look at what can they do.
“Maybe they can’t use a knife and fork. But perhaps they might be able to eat things with their hands. They might not be able to initiate that first bite, but maybe if you go hand-over-hand and use a lot of encouragement, maybe they get the second bite.”
Recognizing the residents’ limits, and one’s own, may even improve those personal relationships, Rogers says. “You could adapt anything,” she says.

Communicating WIth Residents Is The Answer

As Ronch and a growing chorus of person-centered care advocates say, the profession simply has no other choice.
“The question is, what are you talking with them about?” Ronch says. “Instead of having them watch Barbara Walters while you’re in there, take a minute to ask them about those pictures on their desks. What’s the latest from home? What do you hear? Since we know the relationship in caring is crucial to the outcome, this is a great way to have a relationship where the elder isn’t always at a disadvantage, where they’re always the one being done to,” he says.


The alternative is to leave those residents feeling marooned. Facing that, as Defoe knew well five centuries ago, most residents would understand why Crusoe reported that “the tears would run plentifully down my face when I made these reflections, and sometimes I would expostulate with myself, why Providence should thus completely ruin its creatures, and render them so absolutely miserable, so without help abandoned, so entirely depressed, that it could hardly be rational to be thankful for such a life.”