Lorraine Nowak remembers how she used to go dancing. Her husband played in a band, and she used to go to his shows. As she tells me this story, she smiles and shakes her hips from her bed, her hands waving in the air like they just don’t care. She misses those days a lot. She recently injured her hip in a fall, and now her knees cannot hold her weight like they used to. 

At 75 years old, Nowak gets sad talking about the past, and she does not seem to remember how long she’s been in the hospital. She seems resigned to whatever happens next, even if it means she must go to a nursing home without her husband.

“If that’s gonna happen there’s nothing I can do,” she says. “You gotta accept it. Whether you like it or not because that’s part of life.”

In her old age, she swears by the importance of family. “Everything. Family to me is everything,” she says.

Nowak had been receiving treatment at the Hotel Dieu Shaver Health and Rehabilitation Centre for about six weeks at the time of this interview. She now lives in a long-term care home. Her husband remains at their family home.

At age 88, Chris Catcher is in a different situation. He lives alone at his home in Flesherton, Ontario. He lost his wife, my great aunt, Clazien Catcher in July last year. As a single male senior, he is especially vulnerable to loneliness. He misses his wife. Every day in fact. But he takes joy in the community provided to him by his church. He spends his time volunteering with fellow seniors in local nursing homes and making friends amongst the Mennonite Christians in his community. For him, faith is essential to aging gracefully. Faith is essential to staving off the loneliness of
growing old.

Before the pandemic, there was not a lot of public discussion about how seniors experience loneliness. This might be because seniors are statistically less likely to report feelings of loneliness than younger demographics.  

One report from Statistics Canada shows that youth between the ages of 15 and 24 are most vulnerable to loneliness in Canada. The report found that 23%, nearly one in four, self-reported feelings of loneliness often or always.

The same report showed that seniors aged 75 and older only reported feelings of loneliness at a rate of 14 per cent. According to the report, this disparity may be somewhat explained by the fact that young people are more likely to be single and looking for partners. And one of the stronger predictors of loneliness is living alone.  

Most mental health disorders, including depression, bi-polar disorder and generalized anxiety disorder, are more likely to be diagnosed before the age of 30. This also accounts for the disparity in how youth and seniors experience loneliness. And it is why youth are an important demographic to consider when writing policy to reduce loneliness in Canada.

However, the statistics often overlook seniors living in retirement homes and long-term care centers. These studies occasionally overshadow widowed seniors as well because in Canada, senior is a large category consisting of everybody 65 and older. As we narrow the study group to persons over 80 the rate of widowhood rises. This is also when self-reported loneliness begins to spike. 80-year-olds and over tend to make up the majority of the residents in long-term care centers and senior homes as well.

The condition of seniors in long term care homes (LTCs) received a swell of media attention in the first waves of COVID-19. It became impossible to ignore the myriad cracks in the system as the pandemic raged through the country in 2020.

A report in Stats Canada found that 80 per cent of first wave deaths took place in LTCs and senior homes.

In addition to that, the public was bombarded with stories of aging family members, some of them sick with COVID, saying goodbye to their loved ones on a zoom call.

It wasn’t just seniors in LTCs and senior homes being affected though. An Ipsos poll conducted on behalf of Global News found that 40% of people aged 55 and older were experiencing loneliness during the pandemic. This marked a 14 per cent increase from the previous year. As the first wave cleared beds from nursing homes and table settings at dinner tables all over Canada, the truth became impossible to ignore. We had failed to take care of our elderly.

Studying loneliness in senior populations is not easy though. One of the confounding variables in the research is the cognitive decline of seniors. This is especially impactful on the research in nursing homes. In Britain, up to 75%, or three out of four, seniors living in long-term care centers suffer from dementia. Self-reported data collected from these individuals may not always be reliable.

Drageset et al. conducted a study out of Norway assessing loneliness in residents of 30 different nursing homes. While there were over 2042 residents in these homes, only 272 of them were cognitively fit to be interviewed. However, in this sample, the researchers found that 56% reported that they felt lonely. Almost half of them reported feeling this way often. Compared to the numbers reported by Stats Canada, these numbers show self-reported loneliness is three to four times higher for seniors in nursing homes than for seniors living independently in the community.  

Why though? Why is a person like Lorraine Nowak more at risk of loneliness than someone like Chris Catcher? In 2021, the Government of Ontario commissioned an investigation into Ontario’s long-term care system, seeking answers.

Ontario’s Long-Term Care COVID-19 Commission reported in 2021 that when Canada began to develop its system of universal health care in the 1950s, long-term care was not included in the new system. It was left to the private sector to provide the service. In 1984, a few changes to the Canada Health Act turned long-term care into a hybrid model where funding was acquired both through for-profit centers and municipally funded ones.  

Of the 626 long-term care centers in Ontario, 58 per cent are for-profit. Another 24 per cent are not for profit and 16 per cent are municipally run. The research currently shows that for-profit LTCs are outperformed by the other models.

For-profit centers tend to have older infrastructure, more hospital admissions, and have been found to report more instances of excessive use of psychoactive medications. For-profit LTCs also offer lower wages to employees and tend to have higher staff turnover. In January 2021, the science table of Premiere Doug Ford found that for-profit nursing homes were reporting 78% more COVID related deaths than their non-profit alternatives.

Still, both systems suffer from staffing shortages, inadequate infrastructure, and a lack of oversight.

 A report from the Government of Ontario found that 25% of personal support workers (PSWs) with two or three years of experience leave the industry every year. Furthermore, there is no provincially legislated ratio of staff to residents in nursing homes, as a report from the Registered Association of Nurses has pointed out.

Worse still, the skill level of care workers in nursing homes tends to be lower than it is in other care sectors. PSWs provide 65 per cent of the care in LTCs, but personal support is much less regulated than nursing. Registered nurses and registered practical nurses account for nine and 17 per cent of LTC staff respectively. Nurse practitioners, account for only one per cent.

This system, equipped as it is, cannot meet the emotional or physical needs of its residents. When those needs are not appropriately met or managed, seniors tend to become isolated and lonely.

Numerous studies have shown that loneliness and isolation are positively correlated with cognitive decline in seniors. This is one reason seniors in retirement homes and nursing homes have much higher rates of dementia than seniors living in the community.

Loneliness has also been correlated with depression, physical impairments, earlier mortality rates and generally poorer health.

Physical impairments, especially those which limit mobility or restrict movement, represent physical barriers to seniors. They may also make it difficult for seniors to take care of themselves, thus requiring advanced care provided by a hospital or nursing home.

The same impairments may prevent seniors from getting a regular amount of exercise, which can be detrimental to their mental health. One study published by the journal of Geriatric Physical Therapy found that older adults were especially sedentary. It reports that seniors are sedentary for almost 80 per cent of their time.

Many seniors also struggle with the loss of a lifetime partner, like Chris does. Or they may have financial difficulties because of fixed incomes. The transition from family home to nursing home can also be upsetting and can further increase their risk to isolation and loneliness.

There is no one-size fits-all solution to this problem though.

The Canadian Association for Retired Persons (CARP) argues for an at-home care system. Unfortunately, Canada’s at-home care services do not receive the funding that nursing homes receive. As a result, the care for seniors who choose to stay home rather then enter a home tends to fall on the shoulders of family members.

CARP estimates that the labour of family and friends for high-need seniors saves the health care system $66 billion every year. And at-home care is the overwhelming preference of most seniors.

“You’ll be hard pressed to find a senior who says ‘yeah, absolutely, I want to go into a nursing home,’” says Sheridan college professor and founder of www.nursinghomeratings.ca and www.informedsenior.ca Christine Taylor.

In the current model though, with most senior care funding going to nursing homes and retirement centers, at-home care just isn’t a long-term solution for many seniors.

Taylor says that some people underestimate the risk of ending up in senior homes, and so they take a calculated risk in assuming that they will never end up in one.

“At the end of the day, only four to five per cent of seniors are in long term care homes. So they think, ‘well I’ve got a 96% chance of not going that route.’”

Taylor is citing a statistic released from Stats Canada. The problem with that report is that the category of senior includes all people 65 and older. A separate report released in 2016 finds that 32 per cent of people 85 and older live in senior homes and LTCs. The risk of ending up in a long-term care gets higher and higher with age.

Taylor works to find solutions to this problem within the system that currently exists. Her websites, www.nursinghometratings.ca and www.infromedsenior.ca are resources which help seniors to better understand their long term care options as they enter elderhood.

“No one likes to talk about aging. No one likes to talk about their parents getting older,” says Taylor. But avoiding the conversation appears to make options even worse for seniors.

Since people assume that the risk of ending up in a nursing home is lower than it is, very few plan for emergencies. Since most nursing homes have long wait lists, many families will be unable to get their parent or loved one into their first choice of home. Or they might try to home a family member during a medical emergency and might not have time to vet nursing homes before re-homing their loved one. Having open and honest conversations with senior family members early can help to prevent a crisis later in life.

Inside LTCs, care workers attempt to reduce loneliness and isolation by engaging seniors in group activities. But communicating with large groups suffering from dementia is a difficult task even for a well-staffed team. It requires care workers to develop positive one-on-one relationships with the residents. Staffing shortages make this task much harder than it already is.

“If you have a home with many different ethnic groups, you have to know what is going to appeal to most and you have to change your activities on a regular basis,” says Taylor.

As Canada has diversified, so too has the cultural makeup of senior homes. This presents additional challenges for a system attempting to provide a one-size-fits-all solution for a group of people with vastly different needs.

“The nature and course of cognitive impairment and cognitive decline is so varied, that it’s really more about focusing on a person-centered approach,” says Lia Tsotsos, Director for the Centre for Elder Research at Sheridan.

Tsotsos stresses the need for seniors to have good relationships with their care workers but she describes a system where one worker may have to bathe seven people in an hour. “Without enough people, without enough time, you can’t just chat with them for an extra minute or two.”

Fostering social engagement through group activities is an essential part of combating loneliness in nursing homes, but staff don’t have the time to learn about their residents so they can provide stimulating care for them.

“I don’t think its limited to activities though,” says Tsotsos. “It’s food, it’s bedding, it’s how you decorate the room. Are you allowed to just go talk to people?”

This system has become a thing to fear for Canadian seniors. Until it can be fixed, allocating greater funding to at-home care services can help seniors maintain some autonomy and stay close to their families and communities. And As Taylor, suggested, crisis planning can make quite a difference later in life.

Long-term care is a factory of loneliness in Canada. It does not have to stay that way.