The role of individual characteristics and physical frailty on health related quality of life (HRQOL): A cross sectional study of Italian community-dwelling older adults
Introduction
According to Eurostat data (Eurostat, 2012), Italy is one of the “oldest” countries in the world. In Italy, the life expectancy (LE) at birth is now 84 years for women and 79 for men, with a proportion of over 60 years of about 20% in 2011. Unfortunately, the prolonged LE is not accompanied by the increase of healthy life years, defined as disability-free LE, highlighting that we live an increasing number of years in a poor health condition.
Within the context of unhealthy extension of LE, it is necessary to find specific and strong indicators for predicting and preventing negative events of aging. The construct of frailty has been identify as a precursor state of adverse outcomes of aging (e.g., death, hospitalization, dependency in daily activities, institutionalization, falls, fractures, cognitive decline, dementia) (Castell et al., 2013, Chang et al., 2012, Chin et al., 1999, Clegg et al., 2013, Fried et al., 2001, Jones et al., 2004, Rockwood et al., 2005, Rockwood et al., 1999, Speechley and Tinetti, 1991, Winograd et al., 1991). Frailty is a fearsome condition for older adults, defined as a loss of physiologic reserve and an increased vulnerability to external stresses, deriving from multiple and interactive complex systems (Buchner and Wagner, 1992, Fried et al., 2001, Rockwood et al., 2000). Frailty is highly prevalent with increasing age (Collard et al., 2012, Shamliyan et al., 2013). According to the Survey of Health, Aging and Retirement in Europe (Santos-Eggimann, Cuenoud, Spagnoli, & Junod, 2009), 4% of seniors are frail in the age between 50 and 64 years, and 17% in the over 65 years.
Frailty in older adults is closely linked to HRQOL (Chang et al., 2012, Gobbens et al., 2012, Gobbens and van Assen, 2014, Kanwar et al., 2013, Masel et al., 2009). HRQOL refers to the physical, mental, and social domains of health, seen as distinct domains that can be influenced, in a complex way, by individual's experiences, beliefs, expectations, and perceptions (Testa & Simonson, 1996). HRQOL provides a patient point of view on effects of interventions, diseases, and processes acting on people. It is a person-centered outcome measure which is more informative than the traditional measures of mortality and morbidity (Idler and Benyamini, 1997, Tsai et al., 2007).
The role of socio-demographic characteristics and clinical conditions on HRQOL has been widely investigated in previous studies. A lower income and educational attainment seem to be associated with a reduced HRQOL, as well as the medical conditions could have a negative impact on HRQOL (Gobbens et al., 2012, Lubetkin et al., 2005, Zaninotto et al., 2009). Zaninotto et al. (2009) reported a significant association between increasing of age and poor HRQOL; unlike, Netuveli and Blane (2008), and Gobbens et al. (2012) did not find it. Wijnhoven, Kriegsman, Snoek, Hesselink, and de Haan (2003) found a worst HRQOL for women compared to men aged between 56 and 75 years and with asthma; whereas, Kirchengast and Haslinger (2008) found a higher level of HRQOL in women aged between 57 and 70 years compared to men of same age, while did not find significant gender differences in the older group (70 years and over). Several pathological conditions, especially chronic diseases, such as hypertension, osteoarthritis, diabetes, depression, asthma, have a negative effect on HRQOL (Brown et al., 2004, Gallegos-Carrillo et al., 2009, Gobbens and van Assen, 2014, Kempen et al., 1997, Lam and Lauder, 2000). Therefore, most of the studies on HRQOL (Hopman et al., 2009, Kempen et al., 1997, Kimura et al., 2010, Lam and Lauder, 2000) were conducted on subjects suffering from diseases with the aim to evaluate the impact of morbidity or the effectiveness of a treatment or intervention. Studies investigated the relation among individual factors and HRQOL reported controversial findings, as mentioned above. In order to clarify this issue, further studies are needed.
Within the literature of frailty, the association between frailty and HRQOL has been widely analysed. Several studies (Bilotta et al., 2010, Chang et al., 2012, Gobbens et al., 2012, Lin et al., 2011, Masel et al., 2009, Puts et al., 2007) found a significant association between frailty status and impairment in the HRQOL in community-dwelling older adults. Precisely, qualitative interviews conducted with 25 older adults in the Netherlands underlined a lower perception of QOL for frail with respect to robust subjects (Puts et al., 2007). Bilotta et al. (2010) reported that physical frailty status measured according to the Study of Osteoporotic Fractures criteria negatively affected five out of seven dimensions of quality of life (QOL) investigated using the Older People's QOL questionnaire in a sample of Italian older adults. Similarly, a better HRQOL for robust compared to frail and pre-frail subjects was found in Chinese (Chang et al., 2012), Mexican American (Masel et al., 2009), and Taiwanese older adults (Lin et al., 2011). In these studies, frailty and HRQOL were evaluated by using the Fried's criteria and the Short Form-36 questionnaire, respectively. Finally, Gobbens et al. (2012) found significant correlations between frailty and QOL, measured using the Tilburg Frailty Indicator (TFI) and the WHOQOL-BREF questionnaire, in a Dutch sample of older adults.
Despite the large number of studies that have addressed the impact of frailty on HRQOL, we still know little about the weight of single components of frailty on HRQOL. Among the five frailty components of Fried et al. (2001), Lin et al. (2011) found that poor endurance and energy had a largest effect on both mental and physical QOL of older adults measured with SF-36, followed by slowness. Whereas, Chang et al. (2012) identified slowness as the major contributing component in the physical scale of SF-36, and poor endurance and energy in the mental scale of QOL. Using the Study of the Osteoporotic Fractures (SOF) criteria for frailty evaluation, the study by Bilotta et al. (2010) reported “reduced energy level” as the first predictor of QOL. Thus, little is known on the impact of single components of frailty on mental and physical domains of HRQOL.
The current study pursued a twofold aim: (i) to investigate the relationship between individual characteristics (socio-demographic and medical aspects) and HRQOL; (ii) to identify which components of physical frailty measured according to Fried's criteria provided a better explanation of HRQOL.
Section snippets
Study participants and data collection
This research employed a data subset from the Italian Regional project Act on Aging, a longitudinal, intervention research to evaluate the effects of physical and cognitive training in women and men aged 65 years and over. Participants were recruited through the Health Office of Regione Piemonte, general medical practitioners, and local seniors associations. 900 subjects were assessed for eligibility, of which 298 did not meet study's inclusion criteria, 232 declined to participate, and 3 were
Main characteristics of the sample
Table 1 summarizes the main characteristics of participants. Of 259 subjects, the 69% (N = 178) were female and the 53% (N = 137) lived not alone. The mean age was 74 years (SD = 6; range 65–90). The age between women and men was not statistically different.
The 44% (N = 114) of participants had a level of education corresponding to primary school and the 63% (N = 163) had performed a manual job before the retirement (e.g., housewife, seamstress, workman, farmer, mason). A high number of participants (N =
Discussion
In this cross-sectional study we achieved a twofold goal. Firstly, we investigated the role of socio-demographic (gender, age, living condition, education attainment, past job) and medical (use of drugs) aspects on HRQOL. Secondly, among the five frailty components of Fried, we identified the major associated factor for general, mental and physical dimensions of HRQOL.
As far as the first point is concerned, in agreement with previous studies (al-Windi et al., 1999, Lubetkin et al., 2005), we
Conclusions
In sum, our study highlighted the role of individual and medical characteristics as well as the single impact of the five frailty Fried's criteria on HRQOL. Our results improved the specific body of literature about mechanisms and relationships between functioning and self-rated health during the aging process. The discovery of relationship is strongly needed in order to identify risks and protective factors for a better aging and to develop new, individualized, and more effective preventive
Conflict of interest statement
We wish to confirm that there are no known conflicts of interest associated with this publication and there has been no significant financial support for this work that could have influenced its outcome.
Acknowledgments
Research presented in this article has been supported by Regione Piemonte, Direzione e Innovazione Ricerca e Università, Bando Scienze Umane e Sociali 2008 (ID 59), for their contribution to ACT ON AGING study.
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