Qual Life Res (2016) 25:13951407
DOI 10.1007/s11136-015-1197-y
REVIEW
Systematic review of interventions addressing social
isolation and depression in aged care clients
Linel Franck1 Natalie Molyneux1 Lynne Parkinson1
Accepted: 23 November 2015 / Published online: 8 December 2015
 Springer International Publishing Switzerland 2015
Abstract
Objective A systematic review was undertaken of studies
reporting interventions for reducing social isolation and
depression in older people receiving aged care services
(community or residential).
Methods Gray literature and relevant electronic databases
were systematically searched for studies published in
English between January 2009 and December 2013. Two
reviewers independently screened studies for selection
using predetermined inclusion and exclusion criteria and
independently completed methodological quality review at
study level. Studies of poor methodological quality were
excluded. Data were extracted at study level by one
reviewer and independently checked by a second reviewer,
using a standardized form. The results across studies were
qualitatively synthesized with outcomes described and
summarized at last follow-up.
Results Although the original objective was to review
rural studies, no intervention studies based in rural areas
met criteria for inclusion in the review, and only urban
studies could be reviewed. Of 403 articles, six articles
representing five studies with moderate-to-low risk of bias
were included for review. All study participants were older
adults ranging in age from 77 to 86 years. All studies had
small sample sizes, ranging from 26 to 113 participants.
Three of the five included intervention studies successfully
reduced social isolation; one also successfully reduced
depression.
& Lynne Parkinson
l.parkinson@cqu.edu.au
1
Central Queensland University, Building 32,
North Rockhampton, QLD 4701, Australia
Conclusions Only one intervention, group-based remi-
niscence therapy, was reported as successful in reducing
both social isolation and depression in older people within
an urban aged care setting. More research is needed to
explore transferability of interventions across different
aged care settings and into rural areas.
Keywords Systematic review
Intervention

Social isolation
Depression
Aged care
Introduction
Social isolation has been identified as an important factor
in reduced well-being for older people [1, 2]. Social iso-
lation has previously been inconsistently defined. Con-
ceptualizations are often unidimensional, focussing either
on objective and quantifiable elements such as number of
contacts or social interactions [36], or subjective elements
such as the perception of the quality of social interactions
[1]. However, unidimensional, objective definitions of
social isolation can assume that all contacts carry the same
emotional and social value [3]. Instead, multidimensional
conceptualizations describe social isolation as a state in
which individuals experience a deficiency of fulfilling and
quality relationships, may lack a sense of social belonging,
and have limited social engagement and often few social
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
isolated, while another has few contacts yet does not
experience social isolation [7].
The definition of social isolation must also to be consid-
ered in the context of the conceptually related term,
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loneliness. Loneliness has also been inconsistently defined,
making it difficult to distinguish from social isolation. One
way to define loneliness is as an unpleasant emotional
experience arising from a persons perceived discrepancy
between their desired and actual relationships [8]. However,
given the inconsistency in definitions for social isolation in
the literature, and the interchangeable use of social isolation
and loneliness by service providers and policy makers [9],
this review follows Cattan et al. [10] in treating social iso-
lation and loneliness as conceptually synonymous.
The little available research indicates significant global
variation in prevalence estimates of social isolation in older
people. European prevalence estimates for social isolation
vary from 5 to 9 % in Germany, the Netherlands, and
Denmark; 20 % in Portugal, 35 % in Greece, and 39 % in
Finland [11]. Prevalence estimates for the UK (UK) and
Australia are similar, with 717 % of older people often
experiencing social isolation, and up to 31 % of older
people sometimes experiencing social isolation [1215].
A Malaysian study found that 50 % of respondents were at
risk of social isolation [16]. Although the available
prevalence estimates of social isolation vary, the majority
of studies indicate that social isolation is relatively com-
mon in older people.
Studies suggest that prevalence and risk of social iso-
lation are higher for older adults living in residential aged
care settings than for those living in private dwellings
within the community [1722]. For example, studies in
Sweden and Norway have found that approximately 56 %
of nursing home residents are lonely [23, 24]. Although
some research suggests these high estimates may be due to
premature entry to residential care as a result of social
isolation prior to admission [18, 2527], Scocco et al. [28]
suggest that factors in residential aged care settings
aggravate and perpetuate social isolation.
Some studies have found that living in rural areas can
increase the risk of social isolation in older people and may
present a greater health vulnerability to the socially isolated
[29]. A higher prevalence of social isolation was found in
Finnish rural (45 %) compared to urban (40 %) older
people [19]. In China, 78 % of 5652 rural older people
reported moderate-to-severe levels of loneliness [30]. An
increased risk of social isolation in rural older adults was
also found in Australia [22]. The emerging evidence for
increased social isolation in rural areas has relevance to the
Australian context where nearly 30 % of the general pop-
ulation live in rural areas and older people tend to move
from urban to rural areas to retire [3133]. However, there
has only been limited research exploring rural living as a
risk factor for social isolation in older people.
The relatively high prevalence estimates for social iso-
lation are concerning, given that social isolation is
acknowledged as having a detrimental effect on both
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Qual Life Res (2016) 25:13951407
physical and mental health [34]. Research has consistently
demonstrated that social isolation can predict increased
morbidity and mortality [6, 3540], and reduced quality of
life, health, and well-being [4143]. Social isolation has
also frequently been shown to be associated with mental
health concerns, including suicide and depression [4450],
and increased susceptibility to cognitive decline and
dementia [5154]. House [55] found that social isolation
and smoking were comparable in the extent to which they
negatively impact health. This finding was supported in a
meta-analysis by Holt-Lunstad et al. [56], which concluded
that the impact of social relationships on mortality risk was
comparable to that of smoking and alcohol consumption,
and greater than that of physical inactivity and obesity.
There is a significant relationship between social isola-
tion and depression [18, 56, 57]. Social isolation is an
independent risk factor for depressive symptoms [46, 58],
and mortality risk associated with loneliness is partially
explained by health outcomes such as depression [39].
However, Stek et al. [60] found that perceived loneliness or
depression did not independently predict mortality risk,
while perceived loneliness and depression in combination
increased mortality risk 2.1 times [59]. The effects of the
two attributes are difficult to separate, and the relationship
between loneliness and depressive symptoms is not
attributable to demographic variables, dispositional nega-
tivity, stress, social support, or objective social isolation
[39]. Recent research has found that depressive symptoms
in aged residential care clients could be decreased over
time by increasing meaningful social engagement activities
[60].
There is a need to identify effective interventions to
address social isolation and depression in older people,
given the relatively high prevalence and the known health
impacts [61]. Previous systematic reviews have agreed that
the poor methodological quality of intervention studies
impedes definitive conclusions about intervention effec-
tiveness [3, 10, 62]. Despite the limitations found in the
studies available to these reviews, program components
associated with successful interventions have been identi-
fied. These include high-quality training and support of
staff [63], and involving older people in the planning,
implementation, and evaluation of interventions utilitizing
community resources [3, 10, 62]. In addition, Cattan et al.
[10] and Dickens et al. [3] found that group-oriented edu-
cation or social support programs are most effective,
especially when based on a theoretical framework. Previ-
ous systematic reviews of interventions addressing social
isolation expressed the need for development of the evi-
dence base by high-quality evaluation of interventions.
This systematic review update focuses particularly on
studies from the 5 years since the previous similar review
to answer the question: What effective interventions exist
Qual Life Res (2016) 25:13951407
that address social isolation and depression in aged care
clients living in rural settings?
Method
The preferred reporting items for systematic reviews and
meta-analyses (PRISMA) guidelines were followed in
reporting this systematic review [64].
Search strategy
The search strategy was customized to each database using
database-specific Thesaurus terms and subject headings.
Keywords were generated from the domains of social
isolation, loneliness, depression, older adults, community
aged care, residential aged care, rural, regional, and inter-
vention. A computerized search of publications between
January 2009 and December 2013 was conducted in the
electronic databases of MEDLINE, CINAHL with Full
Text, SocINDEX with Full Text, Health Source: Nursing/
Academic Edition, PsycARTICLES, PsycINFO, Academic
Search Complete, and the Psychology and Behavioral
Sciences Collection. Gray literature searches included
Google, government health and aging websites, and aged
care organization websites. All searches were conducted in
July 2014.
Study selection
Two researchers independently screened the titles,
abstracts, and full text of all retrieved articles with a third
researcher being consulted where there was lack of con-
sensus. Studies were selected using the following inclusion
criteria:
Articles published as full reports in English were
included. Letters, abstracts, books, conference proceed-
ings, press releases, newsletters, posters, informal
internet articles, presentations, brochures, and reviews
were excluded.
The study must have been published between January
01, 2009, and December 31, 2013. This timeframe
encompasses 5 years from the most recent similar
review before this review was undertaken.
No exclusions were made on the basis of country of
origin.
Only studies reporting an intervention that addressed
the outcomes of social isolation or loneliness, or the
combination of depression with social isolation or
loneliness were included.
Studies involving participants who were mostly aged
60 years and over were included. Studies where
1397
participants were mostly under the age of 60 years
were excluded.
Studies involving participants receiving aged care
services (community or residential) were included.
Aged care clients are a particularly disadvantaged group
with high levels of depression and social isolation.
Studies where participants were in retirement commu-
nities were excluded, as this is a very different group
from aged care clients, in terms of physical functioning,
access to services, and social opportunities.
Only intervention studies were included, with no design
exclusions.
Although studies conducted in rural areas were pre-
ferred, the limited rural-based research meant that
studies conducted in an urban setting were also
included.
Methodological quality review
Independent methodological quality review was completed
at study level by two reviewers using the Downs and Black
[65] checklist for methodological quality assessment of
randomized and nonrandomized studies of healthcare
interventions. This checklist includes items assessing
quality of reporting, internal validity, and external validity
[65]. Items 126 on this checklist were considered in the
quality review. A high-quality study was quantitatively
considered as having low risk of bias with a score of 19 or
higher on the 26 items considered. A low-quality study was
quantitatively considered as having a high risk of bias with
a score of 13 or below. This review excluded all low-
quality studies in order to increase confidence in the find-
ings of the reviewed interventions. Where there was a lack
of consensus, reviewers came to a mutual agreement
through revision of evidence supporting or refuting items
in the Downs and Black [65] checklist.
Data extraction
Data were extracted at study level by one reviewer and
independently checked by a second reviewer, using a
standardized form that included items related to publication
details, study design, setting, participant characteristics,
intervention characteristics, and results significant to the
review question. Where there was not consensus, a third
reviewer resolved disagreements.
Study synthesis
The results across studies were qualitatively synthesized
with outcomes described and summarized at last follow-up
where data were provided. A meta-analysis was not
123
1398
undertaken given the heterogeneity of methods, measures,
and resultant data.
Results
Study selection
Database and gray literature searches retrieved 828 articles.
Of these, 425 were duplicates, resulting in 403 articles
screened by titles and abstracts, of which 345 did not meet
the inclusion criteria. Full texts were retrieved for the
remaining 58 articles of which a further 36 did not meet the
inclusion criteria and were excluded. Methodological
quality assessment was conducted on the remaining 22
articles, which resulted in the exclusion of a further 16
articles based on a high risk of bias. Only six articles were
identified as having moderate-to-low risk of bias and were
retained for qualitative synthesis. These six articles repre-
sent five discrete studies. This screening process can be
seen in Fig. 1, including the reasons for exclusion of 36 of
the 58 full-text articles.
Quality assessment
Of the five discrete studies, only one was rated as high
quality, [66] with the remainder being of moderate quality
[6771]. Across all studies, the participants were not rep-
resentative of the entire recruitment population. One study
had not recruited participants over the same time period
[69, 70], and reviewers were unable to determine whether
participants were recruited from the same population in
two studies [67, 69, 70]. No studies attempted to conceal
randomized assignment to intervention or to blind either
subjects or those measuring intervention outcomes. It was
unclear whether participants were randomized to the
intervention group by appropriate methods in three studies
[6770]. Only two of the five studies conducted interven-
tions using staff and facilities representative of the treat-
ment most patients receive [67, 69, 70]. Compliance to
interventions could not be determined in two studies [67,
68]. While most studies adjusted for varying follow-up
lengths or held the interval between intervention and out-
come constant, this was unable to be determined in one
study [69, 70]. Another two studies did not take into
account loss of participants to follow-up [66, 71], one of
which also did not sufficiently describe characteristics of
subjects lost to follow-up [71]. Confounders were not
adjusted for in two of the five studies [6971]. No studies
measured or reported the adverse consequences of inter-
ventions. All studies had small sample sizes ranging from
26 [68] to 113 [70] participants, with two studies reporting
a high attrition rate ranging of 26 % [66] and 30 % [69].
123
Qual Life Res (2016) 25:13951407
Study characteristics
The characteristics of the included studies are detailed in
Table 1. Each study was conducted in a different country;
one from Australia [69, 70], one from the USA [68], one
from the UK [67], one from Hong Kong [71], and one from
Taiwan [66]. Studies included two experimental designs
[67, 695]: one quasi-experimental pre- and post-test with
control group design [67], and two quasi-experimental pre-
and post-test design with no control groups [67, 69, 70].
Three of the five studies had a 3-month follow-up [66, 67,
69, 70], with the remaining two following up at 8 weeks
[71] and 10 weeks [68].
All participants were older adults ranging in age from 77
to 86 years. One study had a near equal ratio of male to
female participants [67], and another had an all-male
sample [66]. The participants in the remaining three studies
were predominantly female with males compromising
11 % [68], 15 % [71], and 29 % [69, 70] of the sample
size. All interventions were conducted in an urban resi-
dential aged care facility (RACF) setting.
Three of the interventions were group-based activities
[66, 67, 71], one was an individual activity [69, 70], and
one was a duo activity [68]. Chiang et al. [66] conducted
eight group-based reminiscence therapy interventions
facilitated over a period of 2 months by a postgraduate
student and co-leader who received didactic training and a
reminiscence group therapy manual to complement their
existing experience in the area. Gleibs et al. [67] imple-
mented gender-based social group interventions facilitated
fortnightly by a member of the RACF staff who received
training in delivery of the intervention with support from
the training coordinator at the facility. Tse [71] created an
indoor gardening program with group and individual par-
ticipation aspects. Once a week, participants were taught
by a research team how to carry out gardening activities,
but were responsible for their own plants during the
8 weeks, finishing by sharing experiences and planting
diaries as a group [71]. Kahlbaugh et al. [68] implemented
a duo activity intervention allowing aged care clients to
play a Nintendo Wii game of their choice for 1 h a week
in the company of an undergraduate research assistant.
Travers and Bartlett [69, 70] broadcast a radio program,
which individuals listened to for 1 h daily over 3 months,
requiring only assistance from RACF staff where technical
difficulties arose. This study was the only one to comment
on cost-effectiveness of the intervention, however, only to
the extent of labeling the intervention as being inexpensive
[69, 70]. Other studies provided no details about the cost of
intervention implementation.
Outcome measures were similar across studies, with
some measuring more outcomes than others (see Table 2).
Gleibs et al. [67] measured social identification [72],
Qual Life Res (2016) 25:13951407 1399

Arcles idened through Addional arcles idened

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

Arcles screened aer duplicates

removed
(n = 403)
Screening

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
Eligibility

. 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)
Included

Arcles included in
qualitave synthesis
(n = 6)

Fig. 1 Flow diagram detailing data screening process

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

123
 Table 1 Characteristics of intervention studies to reduce social isolation and depression in aged care clients
1400

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

123
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
size,
demographics,
inclusion criteria,
exclusion
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) 25:13951407
 Table 1 continued
Study Chiang [66]
characteristics
Inclusion: conscious; able to
speak Taiwanese or Mandarin;
aged 65 years and over; MMSE
score over 20
Exclusion: evidence of
significant cognitive
impairment
Intervention Eight weeks of 90-min group
reminiscence therapy sessions
facilitated weekly by a
Masters degree student and
trained co-leader
Control group Waiting list CG met to complete
assessment instruments during
the same weeks as the EG
(pretest, post-test, and 3-month
follow-up)
Outcome measures Loneliness: Revised University
of California Los Angeles
Loneliness Scale (RULS-V3)
[79]
Depression: Center for
Epidemiological Studies
Depression Scale (CES-D)
[78]
Psychological Well-being:
Symptoms Checklist-90-R
(SCL = 90-R) [80]
123
Gleibs [67]
Unable to determine inclusion
and exclusion criteria
Over 3 months, fortnightly
gender-based club meetings
and activities were facilitated
by a staff member of the care
facility of the same gender as
the group
Social Identity: Two items from
a Social Identification Scale
[68] Personal identity
strength: Five items adapted
from a Self-Clarity Scale [73]
and the Personal Identity
Strength Scale [74]
Cognitive Ability:
Addenbrookes Cognitive
Examination Revised (ACE-
R) [78]
Life Satisfaction: Single item
[75]
Anxiety and Depression:
Hospital Anxiety and
Depression Scale (HADS)
[76]
Kahlbaugh [68]
Unable to determine inclusion
and exclusion criteria
Weekly hour-long sessions playing
a Wii game of choice for
10 weeks. A research assistant
was assigned to the same
participant, and visited them at
each session to play Nintendo Wii
CG 1: Weekly hour-long
sessions of watching preferred
TV programs for 10 weeks. A
research assistant was
assigned to the same
participant and visited them
for each session
CG 2: served as a baseline and was
not visited by a research assistant
Loneliness: UCLA Loneliness
Scale V3 [79]
Mood: Positive and Negative
Affect Scale (PANAS) [82]
Physical activity: Adapted
Weekly Physical Activity
Scale [81]
Tse [71]
Inclusion: aged 60 years and
over; able to speak Cantonese;
MMSE score of 6 or more
Exclusion: bed-bound; history
of mental disorders; history of
allergy to pollen, seed,
fertilizer, and plants
Over 8 weeks, gardening activities
and education were facilitated
once a week. Each participant was
responsible for their own planting.
They received a planting diary to
be shared with others
CG: Older people in other
nursing homes received usual
care with no indoor gardening
program participation, but
completed outcome measures
at baseline and 8 weeks
Loneliness: UCLA Loneliness
Scale [79]
Life Satisfaction: Life
Satisfaction Index-A [85]
Social network: Lubben Social
Network Scale (LSNS) [87]
Physical Activity: Modified
Barthel Index [86]
Travers [69, 70]
Inclusion: participants aged 60 years
or over; capable of answering
questionnaires; agreed to listen to
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: participants who
Qual Life Res (2016) 25:13951407
were profoundly deaf; MMSE
score of less than 14
Participants listened to the radio
program for an hour a day over
3 months and recorded listening
activity in a daily diary. Music
and serials from 1920 to 1950
were broadcasted
Social Isolation: two questions
developed by the authors [69]
Loneliness: single-question item
adapted from Victor et al. [90]
Depression: Geriatric Depression
Scale-5 (GDS-5) [88]
Quality of Life: The Quality of
Life Alzheimers Disease Scale
(QOL-AD) and the Alzheimers
Disease Nursing Home Scale
(QOL-AD-NH) [89]
1401
 Table 1 continued
Study Chiang [66]
characteristics
123
Main findings Loneliness: significant
difference between CG and
EG on follow-up test
(z = -27.26, p \ 0.0001,
z = -22.75, p \ 0.0001),
with EG showing
improvement from moderate-
to-mild loneliness
Depression: significant
difference between CG and
EG on post-test and follow-up
(z = -7.09, p \ 0.0001;
z = -7.82, p \ 0.0001), with
EG showing improvement in
depressive symptoms
Psychological well-being:
significant difference between
CG and EG on follow-up test
(z = -10.25, p \ 0.0001,
z = -10.63, p \ 0.0001),
with EG showing improved
psychological well-being
Recommendations Possible facilitators of
and additional improvement include the
intervention group processes of sharing,
information interacting, feedback, and
praise, which encourage
cohesion, friendship, personal
understanding of each other, a
sense of belonging to a group,
and acceptance by a group
Facilitators of reminiscence
therapy were also highly trained
in this evidence-based therapy
There, was however,
approximately a 30 % attrition
rate with common reasons being
scheduling clashes, health
problems or hospitalization, and
a disparity in expectations of the
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
Gleibs [67]
Social identity: significantly
increased over time for males
(p = 0.09), NSD for females
(p = 0.44)
Personal identity: significantly
increased over time for both
males (p = 0.08) and females
(p = 0.04)
Cognitive Ability: no change
in either gender group, all
F \ 0.50
Well-being: life satisfaction
increased significantly for
males over time (p = 0.09),
NSD for females (p = 0.42)
Depression: decreased
significantly over time for
males (p = 0.03), NSD for
females (p = 0.62)
Anxiety: significantly decreased
over time for males
(p = 0.09), NSD for females
(p = 0.39)
Kahlbaugh [68]
Loneliness: EG had lower
loneliness than CG 1 at post-
test (F (2,30) = 6.24,
p \ 0.005)
Mood: NSD (exact p value not
provided)
Physical activity: NSD (exact
p value not provided)
Authors cautioned the potential of
in- and out-group formations.
Program otherwise was
associated with facilitation of a
sense of belonging, enjoyment,
and shared positive emotional
experiences
Although the research assistants
were socially responsive to
participants in both the TV and
Wii groups, actively engaging in
Wii activities may have
facilitated relationships between
the participant and research
assistant in a way that passively
watching TV does not
Tse [71]
Loneliness: significant
reduction for EG compared to
CG (p \ 0.001)
Life Satisfaction: significant
reduction for EG compared to
CG (p \ 0.001)
Social Network: significant
reduction for EG compared to
CG (p \ 0.001)
Physical activity:
NSD (p = 0.06)
Participants report general
impressions of a very positive
experience with feelings of
pleasure, happiness,
responsibility and engagement
in social activity with
increased levels of physical
activity
Does not require previous
gardening experience
1402
Travers [69, 70]
Loneliness: NSD (p = 0.2)
Depression: significant
improvement (t (112) = 2.99,
p = 0.003)
Quality of life: significant
improvement
(t(112) = -4.19, p \ 0.000)
Participant and Carer Interviews:
radio program positively
influenced well-being, morale,
and behavior of older listeners.
Relaxation was most reported
benefit. Listeners with dementia
seemed to receive greatest
benefit. Friendliness and quality
of program highly rated
Positives: Low cost; flexible;
geographically wide-ranging;
reduced agitation in patients
Suggested Improvements: less
chat shows; less heavy
classical music and opera;
music over a greater range of
eras; international music; old
radio serials; stories about past
famous people
Barriers: problems with
reception and interference
with radio signal during
shared signal use prior to
obtaining a dedicated line for
the radio program; faulty leads
on some radios solved by
replacing leads with batteries
Qual Life Res (2016) 25:13951407
Qual Life Res (2016) 25:13951407 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
CG
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
identity strength post-intervention, similar to the males.
They found no change in cognitive function for either
group over time [67]. Kahlbaugh et al. [68] found that
playing Nintendo Wii improves participant well-being,
social connection, and enjoyment, as shown through
decreased loneliness and increased likelihood of positive
mood. Tse [71] concluded that an indoor gardening pro-
gram might decrease loneliness while improving social-
ization and life satisfaction, irrespective of factors such as
age, finances, education, and any level of prior gardening
experience. Participants commented on feelings of plea-
sure, happiness, responsibility, increased physical activity,
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
participants, but did improve depressive symptoms and
quality of life. RACF carers perceived the radio program as
high quality and friendly, and felt it had a positive influ-
ence on participants morale, well-being, relaxation, and
behavior [69, 70].
Study synthesis
Social isolation and depression are the main outcomes of
interest to this review. Of the five included studies, one
found no significant difference in social isolation pre- to
post-intervention [69, 70], and one did not specifically
measure this outcome, despite having the objective to
reduce social isolation [67]. The remaining three studies
reported reducing social isolation [66, 68, 71]. Two of
these three studies, however, found no significant reduction
in depression [9, 71]. The study by Chiang [66] found that
a reminiscence therapy intervention successfully reduced
both social isolation and depression. Therefore, well-
trained staff facilitating group-based activities that offer
support and social interaction through sharing and the
establishment of common ground appear to be the most
successful interventions addressing social isolation and
depression in RACF clients. A qualitative summary of
results by outcome domains can be found in Table 3.
Discussion
This systematic review aimed to identify effective inter-
ventions for reducing social isolation and depression in
aged care clients, with a particular interest in interventions
in rural areas. However, none of the retrieved studies
conducted in a rural context were of sufficient method-
ological quality for inclusion in this review, so this review
could only consider interventions set in urban areas.
Of the five identified interventions to address social
isolation, two cannot be recommended; one study did not
measure social isolation as an outcome [67], and one found
no significant improvement in social isolation [69, 70]. The

123
1404
Table 3 Qualitative summary of main results by measured outcomes, for included studies
Study Chiang [66] Gleibs [67]
Intervention Reminiscence therapy Gender-based social clubs
Follow-up period 3 months 3 months
Social isolation SE NM
Depression SE Males: SE
Females: NSD
SE significant effect, NSD not significantly different, NM not measured
remaining three interventions all significantly reduced
social isolation; however, depression was not measured as
an outcome by two studies [68, 71]. Reminiscence therapy
was the only intervention which significantly reduced both
social isolation and depression and can be considered a
successful intervention addressing both social isolation and
depression in the RACF setting [66]. Based on this study,
the most benefit seemed to be derived from programs that
involved well-trained staff facilitating group-based social
activity or support where social interaction was maximized
through sharing stories and fostering a shared common
ground on which to base interaction.
These results are similar to previous systematic reviews,
supporting the findings that well-trained staff facilitating
social activity or support in group-based formats where
older people are active participants in the program are
common characteristics of effective interventions [3, 10,
63]. Where previous systematic reviews were inconclusive,
this review found three successful interventions of mod-
erate-to-high methodological quality in the RACF setting
[66, 68, 71], all of which reduced social isolation, and one
which also reduced depression [66].
This systematic review builds on the evidence base
established by previous reviews by retrieving data from
studies of any design, published from 2009 to 2013, by
considering a wider range of outcomes consistent with a
multidimensional definition of social isolation, and by
including the context of the risk factors for aged care set-
tings [3, 10, 63]. The use of a 5-year date range enables
identification of interventions published since the most
recent identified systematic review. Reviewing only studies
published in English may have introduced bias [91];
however, pragmatic limitations necessitated this decision.
Through the use of a comprehensive search strategy, tai-
lored to each individual database, and by enforcing no
limitation on study design, the likelihood of retrieving
potential intervention studies was increased. The incon-
sistent definition of social isolation and its relationship to
loneliness remains a barrier to research in this domain and
has implications for the identification and interpretation of
interventions. This review used a theoretically supported
123
Qual Life Res (2016) 25:13951407
Kahlbaugh [68] Tse [71] Travers [69, 70]
Playing Nintendo Wii Indoor gardening program Radio program
10 weeks 8 weeks 3 months
SE SE NSD
NM NM SE
definition of social isolation and considered related con-
cepts in the search strategy to capture relevant intervention
studies.
Although many studies that may have reported viable
interventions were excluded due to poor quality
throughout the methodological quality review process, the
inclusion of only moderate-to-high-quality studies
improves the confidence with which conclusions can be
made in this review. Generalizability of results across
countries is, however, difficult, given that aged care
organizations and their definition of standard care may
differ across countries.
Future research should consider the transferability of the
identified successful interventions to other aged care (such
as community-based care) and geographical settings.
During implementation and evaluation of interventions, it
is important that information about costs, sustainability,
long-term effectiveness, staff training, barriers, and facili-
tators be detailed, to inform service providers about
effective implementation and transferability of programs to
other situations. It is essential that future research includes
adequate evaluation of intervention effects, with appro-
priate experimental design and reliable measures to maxi-
mize confidence in research findings. Additionally, there is
a need to establish clear and consistent definitions of terms
such as social isolation, loneliness, social connectedness,
social integration and so on, including clear distinction
between these terms. This clarification would improve
measurement of these concepts, and consequently the
design of interventions, comparability across studies, and
then potential transferability.
In summary, this systematic review identified one
intervention, reminiscence therapy, that successfully
addressed both social isolation and depression in urban
RACF clients [66]. Two interventions successfully reduced
social isolation, but not depression [68, 71]. The effec-
tiveness or feasibility of these interventions in the rural
context is yet to be established; it remains unclear how
interventions from urban settings would need to be modi-
fied for rural settings. This is an important gap for future
research.
Qual Life Res (2016) 25:13951407
Acknowledgments PresCare organization provided funding for the
overall project. This review was conducted as part of Linel Francks
Honours Psychology project at Central Queensland University.
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