Ageing Well: Quality Of Life In Old Age (Growing Older)

This book explores concepts of quality of life in older age in the theoretical Ageing Well is key reading for students, academics, practitioners and policy makers.
Table of contents

One of the significant findings of this study was that assessment of quality of life should include factors other than health. However, in a Brazilian study that used similar methodology, health was the most stated response to most questions on what is currently wrong with and what could increase or decrease their quality of life. In a national survey of individuals aged 65 years or more, living in England and Scotland, Bowling and colleagues tried to find out older people's concepts about quality of life by asking them.

The same order stood for factors constituting good quality of life while health and home and neighbourhood came on the top as factors that can take away quality of life. Gabriel and Bowling attempted to develop a conceptual framework about the quality of life using older people's views. In a recent study from Sweden, men and women aged more than 67 years were asked what quality of life was for them; responses in rank order were social relations, health, activities, functional ability, well-being, living in one's own home, personal finances, and personal beliefs and attitudes.

These studies clearly demonstrate that quality of life goes beyond health; other factors such as having good social relations, being active and able to participate in socially and personally meaningful activities and having no functional limitations are sometimes more important for older people. It is logical to wonder whether these perceptions are a result of older people living now having less health problems. The widely accepted definition of successful ageing by Rowe and Kahn contains three components: The distinction between successful ageing and quality of life lies in the emphasis on physical health for defining successful ageing.

However, well-being is often incorporated into the concept of successful ageing and ageing well adds to the quality of life. It might also be possible that there are definitions of health which are akin to that of quality of life, for example, health as going and doing something meaningful. The influence of age on quality of life can be due to a direct effect of ageing and indirectly through the effect of ageing on factors that influence quality of life.

From being marginal and dependent, the older person has become active and flourishing as a new life course period—the third age, the period between exit from labour force and the beginning of physical dependency—has emerged. The age curve showed that as one progressed from 50 years onwards, the quality of life actually increased and peaked at 68 years before it started to decline.

It decreased below the level of quality of life at age 50 only after 86 years of age.

As age increased the confidence intervals became wider suggesting that individual variations in factors influencing quality of life increased with age. Studies had noted the stability of life satisfaction in the older ages in the face of decline in objective measures of well-being leading to a paradox. Quality of life was found to be significantly higher in the elderly people compared with younger people using an individual quality of life measure the Schedule for the Evaluation of Individual Quality of Life, SElQoL in which individuals identify five most important areas in their life and weigh them according to their significance.

Adaptation is sometimes used as an explanation of how good quality of life is maintained in old age. In the Berlin Ageing Study, it is described in terms of selection, compensation and optimization. Adaptation is also described in terms of response shift, by which individuals change their internal standards, values and conceptualizations of quality of life to accommodate some hardship or negative circumstance. Closely allied to adaptation is resilience, which is the phenomenon of people beating the odds and doing well against expectation. A mediating role for older people's sense of mastery of their environment has been suggested to improve life satisfaction.

There is an ethical dimension to adaptation that is salient to quality of life in older people: Social comparison plays a role in preservation of quality of life in older ages as health and other circumstances deteriorate. High-quality social relations add to the quality of life in older ages. Quality of social networks predict higher CASP scores 32 and promotes resilience so that high quality of life was maintained in the presence of limiting long-standing illness. The perception of control is believed to contribute to well-being. In the Berlin Aging Study, the belief that one has control over the desired out come was shown to have a positive effect on emotional well-being.

A third type of control that one was responsible for an undesired out come was negatively associated with emotional well-being in cross-sectional studies while positively associated in longitudinal analysis. Studies on ethnic differences on quality of life of elderly people are few. One reason might be the perception that ethnic minorities form a small segment of the population, are relatively younger and are independent of the social institutions for support in old age.

Grewal and colleagues did a qualitative interview study of 73 purposively selected individuals from Fourth National Survey of Ethnic Minorities conducted in England and Wales in — One of the major influences identified in the qualitative study was the sense of purpose and the feeling of usefulness generated by having a role.


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Other significant influences were from the support networks from family, friends and religion. For all ethnic groups spouses and partners were sources of love and companionship, often the link to wider family and social networks. Bereavement brought in loss of companionship and sometimes practical support. Family support for white ethnic groups came from siblings, whereas for the minority ethnic groups, children were the main source.

Across the ethnic groups respondents received support from friends and religion although there was some difference between White and minority ethnic groups. There were greater diversity in terms of income and wealth, and health.

Quality of life at older ages: evidence from the English longitudinal study of aging (wave 1)

One of the ways in which the impact of these influences was felt is through the limitation they bring upon the roles the respondents wanted to play. The companion quantitative study found differences among ethnic groups in the factors studied and in the responses to the factors. Quality of life constitutes the highest level of health outcomes that start with biological and physiological factors and proceed through symptoms, functional states and general health perceptions.

The value assigned to the duration of life as modified by the impairments, functional states, perceptions and social opportunities that are influenced by disease, injury, treatment or policy. Often more than one measure of generic health-related quality of life was used.

Disease-specific health-related quality of life measures were used in less than a quarter of the studies reviewed and the commonest measure was Minnesota Living with Heart Failure Questionnaire MLHFQ. However, the authors identified problems with health-related quality of life in the aged; none of the studies reviewed used a measure developed specific to old age and partly as a result of this health-related quality of life were biased towards physical functioning at the expense of other dimensions, which might be important for older age groups.

This leads to the well-being paradox mentioned above. Comparisons of health-related quality of life between the young and the old in the same study can be used to unravel some of these problems. In one of the studies where it has been done, Trief et al. As would be expected, the older group fared badly on the physical component while doing better on the mental component of the generic measure. The elderly had greater satisfaction, lesser impact on emotions and better coping abilities in the disease-specific measures.

The studies reviewed by Hickey also reiterate these findings for elderly patients with cardio-vascular, neurological and mental health problems. Quality of life in dementia raises important issues about its assessment. Almost all definitions of quality of life expect individuals to make the assessment of their quality of life. Efforts to improve quality of life in early old age need to address financial hardships, functionally limiting disease, lack of at least one trusting relationship, and inability to move out of a disfavoured neighbourhood.

There is the potential for improved quality of life in early old age the third age if these factors are controlled. The nature of old age in countries like Britain is changing because of a combination of the increase in life expectancy at middle age, 1 the tendency towards early retirement, 2 and the availability of pensions. Former notions of old age are being made obsolete by these sociodemographic changes. Although Laslett's ideas have been challenged, he is describing a real phenomenon that has important policy implications.

Policies such as statutory regulation of institutional care and financial support for informal carers are needed to preserve quality of life in the fourth age whereas the third age involves market relations the grey pound , autonomy, and policies designed to maximise quality of life and postpone the onset of physical dependency, with its need for health and welfare services. Aging is perceived to decrease quality of life 8 ; however, when controlled for other factors, the effects of age may disappear.

Significant events during this stage of the life span include loss of income because of exit from the labour force and the increasing probability of illness. Measures of subjective wellbeing have been shown to be associated with financial situation and health and functioning. There is a burgeoning literature on quality of life. A systematic review on quality of life as measured using patient assessed health outcomes showed that only a small portion of the studies deal with older age groups, 20 although the volume of relevant literature will increase if studies from social sciences on wellbeing, life satisfaction, and happiness are included.

We have used data from the first wave of the ELSA. The technical details of this study and the results of primary analyses have been published 24 also available at the web site of the Institute of Fiscal Studies http: The distributions of issued and achieved samples were similar with only a minimal bias towards younger age groups in the issued sample see tables 9. Some of the items were reverse coded so that all item responses were in the same direction.

High scores corresponded to higher quality of life. We selected variables related to health, functioning, social relations, and material circumstances as our predictor variables. Health variables included binary variables to note the presence of longstanding illness and limitations attributable to longstanding illness, and a depression indicator based on the eight item Center for Epidemiological Studies depression scale dichotomised so that a score of 3 or more denotes depression.

Any recorded difficulty in each group was simply summed to create final scores. There was also a variable to indicate whether support for limitation in every day activities was available or not. A number of binary variables referring to the nature of a person's social relations were adopted: We have distinguished three aspects of social network: These were elicited in the survey as multiple item questions with ordinal multiple responses.

In all instances of multiple item scales, we created summary scores by adding item responses after recoding to ensure uniform direction of response. We combined quality and frequency scores for children and family while those for friends were kept separate. In addition, we included the characteristics of the neighbourhood based on a nine item scale, recording area characteristics such as presence of vandalism, a sense of belonging, and perceptions of trust and support.

Quality of life at older ages: evidence from the English longitudinal study of aging (wave 1)

For this simple summary index, higher scores meant better neighbourhoods. Three variables represented material circumstances: Our analysis was conducted in two phases: The analyses were repeated for these imputed datasets and the final parameter estimates obtained by using Rubin's rule. To investigate the effect of age and sex further we repeated the analysis separately for three age groups: All analyses were done using Stata version 8. A large proportion of them , Women had a significant, albeit small, advantage over men.

We repeated analyses for the complete and the five filled in datasets. We found physical health, functioning, and mental health had great influence on quality of life. Equally strong was the influence of factors representing material wellbeing. Economic inactivity because of unemployment reduced quality of life; conversely retirement improved it. Social relationships and circumstances can have positive effects on quality of life.

Quality of life increased with trusting relationships with children and family 0. Similarly, greater frequency of contacts with friends significantly raised quality of life 0. Living in a neighbourhood perceived to be good increased quality of life 0. But all social relationships need not have such positive outcomes. Greater frequency of contacts with children and family, caring for someone, and looking after home or family could significantly reduce quality of life. Conversely doing volunteer work would improve quality of life 0.

Significant positive influences were good neighbourhood 0. We repeated the above analyses for three age groups: The influence of different factors varied between age groups. The 50—64 years old had results similar to the general model described above. In this age group, being retired 1. In 65—74 years old volunteer work and looking after home were also not significant while frequency of contacts with children and family significantly reduced quality of life in this group only.

But they had greater positive impact of volunteer work 2. From there it gradually starts to decline, reaching the same level as at 50 years by 86 years. We examined for gender effects by running models separately for men and women results not shown. For women the quality of life was reduced by being a carer, being not in employment because of looking after home and family, and having increased frequency of contact with children and family.

For men all these factors were not significant.

Introduction: the emergence of a European perspective on ageing

Retirement significantly increased quality of life in men but was not significant for women. On the other hand, longstanding illness reduced quality of life significantly in men but not in women. There was no single key determinant of quality of life; and all the variables in our model were statistically significant. There are key influences that have a negative impact on quality of life and may be amenable to change or adaptation.

These include having a perceived poor financial situation, depression, functional limitations attributable to longstanding illness, and limitations in mobility, activities of daily living, and instrumental activities of daily living. The factors that had positive effect on quality of life included being resident in a neighbourhood perceived to be good, having trusting relationships with children, family, and friends, and affluence as shown by having access to owning two or more motor cars.

The study draws strength from addressing the changed nature of old age both demographically and theoretically, from its use of an important new national dataset on aging and its use of a measure of quality of life that is valid and reliable when applied to older age groups. Our data come from a large nationally representative sample of the older population of England, 24 which makes our findings directly relevant to policy makers.

Aging is perceived to decrease quality of life, but the emergence of a third age demands we look for predictors of quality of life other than age. There is some evidence that the ability to operationalise such strategies, for example, in response to ill health, disability or bereavement, is associated with higher levels of life satisfaction and quality of life Freund and Baltes Feelings of independence, control and autonomy are essential for well-being in old age.

However, this does not mean that the concepts are the same. Clearly, quality of life has a frame of reference which is broader than ageing. Also, successful ageing has a built-in value orientation, and the bulk of the research which has been carried out in this field has focused on individual measures of life satisfaction, morale and other psychological characteristics.

Objectives

Indeed, the concept originated in the development of life satisfaction and morale scales in the US in the s Neugarten et al. In contrast, quality of life is a broader concept evolving from a variety of disciplinary perspectives, mainly sociological, biomedical, psychological, economic and environmental. In the light of the narrower focus of research on successful ageing than on quality of life, perhaps it is not surprising that the extensive literature review conducted by Brown et al. In addition, the concept of successful ageing has been subject to a variety of criticisms such as its bias towards expert assessments Brown et al.

Although quality of life may be criticised for its amorphous nature, there is no doubt that it is a broad-based, multidisciplinary concept and one that is the focus of increasing interest among gerontologists. As noted previously, an important driver of this interest is the policy-making process. Several strands of recent research in this field may be emphasised. The danger with the previous approach to assessing quality of life in old age, and one which has dominated both scientific and professional worlds, was that it tended to homogenise older people, rather than recognising diversity and differences based on, for example, age, gender, race and ethnicity, and disability.

A key element in this homogenisation is the prevailing use of statistical techniques which focus on means and general coefficients of association, rather than on internal sample differentiation see Singer and Ryff for a review of statistical methods addressing diversity. Also inherent in this paradigm was a conception of older age as a distinct phase of the life course, i. In its place, interpretive approaches are gradually appearing which aim, among other things, to build on the implicit theories of quality of life held by older people themselves. Combining the strengths of these two approaches operationally calls for both quantitative and qualitative research methods.

The recent research of Gabriel and Bowling a , b , under the UK Growing Older Programme, well illustrates this emerging scientific paradigm in which theoretical models are integrated with lay perspectives. This research involved comparisons of the results from a representative national survey of older people, based on a hierarchical multiple regression analysis of theoretically derived quality of life indicators Bowling et al.

The variables which explained most of the variance in quality of life ratings were social comparisons and expectations, personality and psychological characteristics optimism, pessimism , health and functional status, personal social capital social activities, contacts and support, loneliness and external, neighbourhood social capital perceived quality of neighbourhood facilities and safety. Socio-economic indicators appeared to contribute relatively little to the model although their indirect influence is likely.

The main themes which were categorised from responses to the open-ended question on the things which gave quality to life were, in order of magnitude, social relationships, social roles and social activities, activities undertaken alone, health, psychological well-being, home and neighbourhood, financial circumstances and independence. The in-depth interviews with a sub-sample of survey respondents led to a similar categorisation of the good things which gave quality to life—again in order of magnitude, social relationships, home and neighbourhood, psychological well-being, solo activities, health, social roles and activities with others, financial circumstances and independence.

On the negative side, the main factors which took quality away from their lives were a poor home and neighbourhood, poor health and poor social relationships. In order to obtain a rich understanding of the meaning of quality of life in old age, the results of these different perspectives were combined using thematic coding of the qualitative data which were compared with the quantitative data Gabriel and Bowling b , p. This suggests that quality of life in old age depends on psychological characteristics, health and functioning, social activities, neighbourhood as well as perceived financial circumstances and independence, and is influenced by social comparisons and expectations.

These main determinants of quality of life were also supported in representative research on ethic differences in quality of life in old age in the UK, albeit not in the same order Nazroo et al. At the European level, the Ageing Well project is an ambitious attempt to operationalise five key components of quality of life physical health and functioning, mental efficacy, life activity, material security and social support and to estimate their direct causal contribution to the outcome variable ageing well. Although the chosen domains were derived from previous research and there were no distinct lay inputs to the process, this project is likely to produce important comparative European data for research on quality of life in old age.

The research was carried out in and in six European countries Austria, Italy, Luxembourg, The Netherlands, Sweden and the UK where representative national samples of people aged over 50 were interviewed Ferring et al. These sorts of purpose-built data are essential to supplement the increasing amount of comparative European data generated by Eurostat based on general population surveys such as the European Household Panel Survey. The final part of this article turns from a consideration of what we know to an outline of what more we need to know and do as a European research community.

It draws on the recommendations to emerge from the series of meetings convened by the European FORUM project which started with a multidisciplinary scientific workshop on quality of life in old age in Heidelberg in September , the results of which were fed into a meeting of the European Forum on Population Ageing Research in March , along with those from parallel workshops on the topics of health and social care and genetics, longevity and demography.

The outcomes were passed on to a user consultation meeting in June and then back to a second workshop on quality of life, in London, the following October. The endpoint of this iterative process was when the results of the quality of life and other workshops were fed into the second meeting of the European Forum in June Thus, the final recommendations were generated not only by meetings involving many of the leading European scientists working in this field but also by end-user groups and those responsible for the national funding of ageing research.

A wide range of recommendations were made, including to national and European research policy makers, but here I will focus only on three sets concerning quality of life—research priorities and knowledge gaps, European and interdisciplinary collaboration, and methodological issues.

Introduction

The full set of recommendations, including those covering the topics of health and social care and genetics, longevity and demography, and those intended for national and European research funders and policy makers, can be viewed on the FORUM website http: Again, it must be emphasised that these are not the personal views of the author but the results of a consensual iterative process, involving key scientists, end users and funders of research.

A clear message to emerge from the discussions about quality of life is that European comparative research is greatly inhibited by the wide variations in the type and quality of data available on this topic in different countries. There is an urgent need for comparable approaches and measures to be adopted, if the full potential of European research is to be realised.

A second structural limitation is the very uneven nature of research capacity and competence across Europe, which results from wide variations in the levels of funding and other support for ageing research. Discussions of research priorities were focused on four broad areas—environmental resources, socio-demographic and economic resources, health resources, and personal resources, social participation and support networks.

The main reason why person—environment transactions are so necessary to the discussion of quality of life in old age is that there is a gap in the descriptive data concerning the everyday lives of older people. These data would assist ageing research in general as well as being able to inform policy makers about the similarities and differences in the everyday lives of older people across Europe.

The scientific discussion about the role of the environments of ageing envisaged a three-dimensional framework linking together individual factors from health and personal ability to life story , psychological and social factors security, loneliness, autonomy, attachment, diversity, cohort, ethnicity, culture, gender, material resources and environmental factors migration, transport, accommodation, technology, neighbourhood, the natural world.

Within this framework, the urgent priorities for research in the environmental dimension include:. Three key priority issues were highlighted with regard to socio-demographic and economic resources. First, quality of life research needs to explore further the question of diversity. For example, there is a need to understand the causal factors behind inequalities between countries and social groups, including the extent to which some circumstances and experiences are universal and how the priority order of factors determining quality varies between different groups of older people.

Given the changes in male and female life course trajectories, it is important to investigate issues such as gendered changes in working life, the experience of long-term and discontinuous employment, changes in pension policy, the transition to retirement and their impact on quality of life.

Second, it is important to focus research on the economic status of future cohorts of older people, and the relationship between ageing and income and other material resources. For example, new knowledge is required on how the income needs of older people change as they age, on their perceptions of income and how these change over time. Too little is known about wealth and inheritance, including the economic power of older people in society and within families, and how wealth is transmitted between generations.

What is the impact of inherited wealth within families? What is the impact on potential demand for long-term care services? What is the impact on financial markets? The absence of reliable data on this topic means that new research is needed to collect comparative information on wealth and goods in kind at both the individual and household levels. Third, further research is required on employment in later life and the transition to retirement. For example, what are the economic incentives to continue to work in later life?

What is the relationship between work, age of exit from the labour market, pensions and inheritance?

A European perspective on quality of life in old age

What inequalities exist among older people? Are there new ones or are the classic inequalities persistent? Is there polarisation or convergence within countries and between them? In the field of health resources , two different sets of research priorities were identified. For one, there are those concerning research reviews in preparation for European collaboration.

For example, reviews are needed of the existing conceptual and empirical research relating to the concept of quality of life, covering not only subjective quality of life but also all aspects relevant for individual agency such as resources and competence. To prepare for comparative research, it is also necessary to review analyses of policy, health systems, societal structure and cultures.

In addition to the need for preparatory reviews, there are five specific field research priorities:. A large number of priorities were highlighted in the field of personal resources , social participation and support networks , a small selection of which are reported here:. A continuous thread running through the whole FORUM process, beginning with scientists from a wide range of disciplines, was the strong support for both greater European comparative research and knowledge sharing and interdisciplinary research.

Comparative research is necessary not only to share knowledge and good practice but also to provide a critical perspective on the portability of different models of practice. Comparisons are needed of quality of life in old age in different European countries, because the existing aggregate data provide only a superficial view, and such studies must relate quality of life to the national cultural and institutional context. Scientists felt that the importance of comparative research was not always recognised by national research funders and, to demonstrate this, they suggested projects on specific policy issues common to several countries to establish good practice within different cultural contexts.

With regard to interdisciplinary collaboration, scientists emphasised the importance of disciplinary identities but also stressed the need to integrate knowledge to produce broader models of quality of life. The essential point is that the nature of the collaboration should be determined by the specific research question and, therefore, a range of different sorts of interdisciplinary work may be envisaged.