Determinants of quality of life in community-dwelling older adults: comparing three cut-offs on the excellent-to-poor spectrum

Perceived Physical Health and Cognitive Behavioral Therapy vs Supportive Psychotherapy Outcomes in Adults With Late-Life Depression: A Secondary Analysis of a Randomized Clinical Trial

Importance

Physical diseases co-occur with late-life depression (LLD). The influence of physical diseases and the subjective perception of physical health (PPH) on treatment outcome in LLD, however, is not well understood.

Objective

To assess the association of physical diseases and PPH with the outcomes of 2 different types of psychotherapy in LLD.

Design, Setting, and Participants

This post hoc secondary analysis of a multicenter, observer-blinded, controlled, parallel-group randomized clinical trial assessed participants 60 years or older with moderate to severe depression recruited at 7 psychiatric-psychotherapeutic outpatient trial sites in Germany from October 1, 2018, to November 11, 2020. Data analysis was performed from April 1 to October 31, 2023.

Interventions

Patients received LLD-specific cognitive behavioral therapy (LLD-CBT) or supportive unspecific intervention (SUI).

Main Outcomes and Measures

Depression severity, response, and remission were measured during treatment and at 6-month follow-up by the change in the 30-item Geriatric Depression Scale (GDS) score. Physical health and PPH were assessed by the number of physical diseases, Charlson Comorbidity Index (CCI), and the World Health Organization Quality of Life Brief Version physical health subscale.

Results

A total of 251 patients were randomized to LLD-CBT (n = 126) or SUI (n = 125), of whom 229 (mean [SD] age, 70.2 [7.1] years; 151 [66%] female) were included in the intention-to-treat analysis. Patients with low and moderate PPH at baseline had significantly less reduction in the GDS score across both treatment groups than patients with high PPH (estimated marginal mean difference [EMMD], 2.67; 95% CI, 0.37-4.97; P = .02 for low PPH and EMMD, 1.82; 95% CI, 0.22-3.42; P = .03 for moderate vs high PPH). Higher PPH at baseline was associated with higher likelihood of response (odds ratio [OR], 1.04; 95% CI, 1.00-1.06; P = .009) and remission at the end of treatment (OR, 1.04; 95% CI, 1.02-1.08; P = .002) and response (OR, 1.05; 95% CI, 1.02-1.08; P < .001) and remission at follow-up (OR, 1.06; 95% CI, 1.03-1.10; P < .001) across both treatment groups. However, a significant interaction of PPH with treatment group was observed with low PPH at baseline being associated with significantly larger reduction in GDS scores in SUI compared with LLD-CBT at the end of treatment (EMMD, -6.48; 95% CI, -11.31 to -1.64; P = .009) and follow-up (EMMD, -6.49; 95% CI, -11.51 to -1.47; P = .01). In contrast, patients with high PPH at baseline had a significantly greater reduction in GDS scores in LLD-CBT compared with SUI at all time points (week 5: EMMD, -4.08; 95% CI, -6.49 to -1.67; P = .001; end-of-treatment: EMMD, -3.67; 95% CI, -6.72 to -0.61; P = .02; and follow-up: EMMD, -3.57; 95% CI, -6.63 to -0.51; P = .02). The number of physical diseases or CCI at baseline did not have an effect on the change in GDS score, response, or remission, neither across both groups nor within either group.

Conclusions and Relevance

In this secondary analysis of a randomized clinical trial, subjective PPH was associated with treatment outcome, response, and remission in psychotherapy of LLD. Patients with LLD responded differently to LLD-CBT and SUI, depending on their baseline PPH score. Treatment approaches for patients with LLD should address PPH in personalized interventions.

Trial Registration

ClinicalTrials.gov Identifier: NCT03735576; Deutsches Register Klinischer Studien Identifier: DRKS00013769.

The Impact of Physical Activity Levels and Functional Fitness Status on the Quality of Life Perceived by Older Adults Living in Rural and Urban Areas: The Portuguese Inland Case

Health-related quality of life (HRQoL) is influenced by several factors, such as living place, physical activity (PA), and functional fitness levels. Evidence shows that functional fitness and PA levels are strongly associated with positive HRQoL, especially in the older population. However, the impact of the living place has not been investigated as an influencing variable in this context. Therefore, this study aimed to investigate the relationship between the HRQoL, PA, and functional fitness of older adults living in rural and urban areas of Portugal. A cross-sectional study was performed with community-dwelling adults aged 65 years and over (n = 261) living in the city of Guarda. The participants were assessed for sociodemographic, anthropometric, clinical health, HRQoL, PA levels, and functional fitness status. The results showed that rural residents presented higher scores of HRQoL and functional fitness than older individuals living in urban areas. Regression models showed that functional fitness variables influence the HRQoL overall score and mental and physical subcomponents of HRQoL, regardless of the living place. In contrast, PA levels only influenced the HRQoL score in rural residents. The findings suggest that intervention programs to improve the physical health, quality of life, and well-being of the older population need to consider the country’s different geographical areas.

A mediational analysis of adverse experiences in childhood and quality of life in adulthood

OBJECTIVES

This study examined associations of three prevalent adverse childhood experiences (ACEs) - parents' problematic alcohol use (PPAU), parental separation/divorce, and lack of support from a trusted adult-with adult quality of life (QoL), and potential mediators of associations.

METHODS

Data were from a representative survey (N = 28,047) in Norway that assessed ACEs, QoL, and potential mediators: enduring perceptions of childhood hardships (Difficult Childhood Questionnaire; DCQ), current mental distress, and current social isolation. Latent regression analyses examined potential mediators.

RESULTS

Each ACE was positively associated with perceptions of childhood as difficult (higher DCQ scores). In turn, ACEs were negatively associated with adult QoL through indirect effects. Lack of support from a trusted adult had the strongest negative association with adult QoL, compared to PPAU and parental separation/divorce. The association between the ACEs and QoL was explained through the mediators of mental distress and social isolation.

CONCLUSIONS

Of the examined ACEs, lack of support from a trusted adult had the strongest negative impact on adult QoL. Adult support to vulnerable children could potentially ameliorate adult consequences of ACEs. In addition, adults reporting difficulties due to childhood adversities may benefit from therapeutic interventions that address both psychological distress and isolation.

Translation, cross-cultural adaptation, and psychometric properties of the Brazilian Portuguese version of the Consumer Financial Protection Bureau Financial Well-Being scale

OBJECTIVE

To translate and back-translate the Consumer Financial Protection Bureau (CFPB) Financial Well-Being Scale into Brazilian Portuguese, to assess its cross-cultural semantic equivalence, and to verify the psychometric properties of the final version.

METHODS

Adaptation of the original scale applied a three-step methodology: translation and back-translation, appreciation of semantic equivalence, and administration to a convenience sample of 834 subjects. The analysis of psychometric properties comprised evaluation of evidence of the instrument's validity by factor analysis, validity by contrasting groups, and internal consistency with Cronbach's alpha coefficient. The CFPB granted authorization to conduct cross-cultural adaptation into Brazilian Portuguese.

RESULTS

Results indicated adequate cultural adaptation between scales, with good equivalence between the original English version and the final Brazilian version. The Cronbach's alpha coefficient for the instrument's internal consistency in this sample was 0.89. Exploratory and confirmatory factor analyses demonstrated high levels of item reliability and goodness of fit, with all 10 items loading onto a single factor, financial well-being. The measure has shown structural stability in two different cultural contexts (Brazil and the USA).

CONCLUSION

The Brazilian version demonstrated acceptable psychometric properties and adequate structural and cross-cultural validity and the participants found it easy to understand.

How is quality of life defined and assessed in published research?

PURPOSE

To ensure clarity in communication in the field of quality of life research, and meaningful use of 'quality of life' as a research outcome, requires two things: awareness that there is a range of conceptualisations and definitions of 'quality of life', and for any particular study, consistency between the way the term is defined and operationalised in that setting. We aimed to identify how frequently research articles described (HR)QOL as a construct of interest, how frequently they referred to "patient-reported outcome (measures)", which patient-reported outcome measures were used, and how (HR)QOL was defined.

METHODS

We reviewed all Quality of Life Research articles published in 2017 and recorded whether they described health-related quality of life or quality of life as constructs of interest, and/or mentioned the term(s) patient-reported outcome (measures). We recorded definitions of (HR)QOL stated and questionnaires used. We classified articles according to constructs assessed and instruments used, and examined whether articles citing the same definition used the same questionnaires.

RESULTS

We reviewed 300 articles; 65% stated that (HR)QOL was a construct of interest, 27% mentioned patient-reported outcome (measures), and 20% mentioned neither. Fifty-one articles provided definitions of (HR)QOL, citing 66 sources, with 11 definitions cited more than once. PROMIS, SF, EQ-5D, and EORTC instruments were the most commonly used. The only definition and questionnaire consistently used together were the WHO definitions/instruments.

CONCLUSION

These results demonstrate considerable heterogeneity in the definition and operationalisation of (HR)QOL, between and within studies. This limits meaningful interpretation of (HR)QOL scores and complicates literature searches. Investigators should define constructs and select instruments aligned with their definitions.

Health-Related Quality of Life in Community-Dwelling Older People with Cognitive Impairment: EQ-5D-3L Measurement Properties

BACKGROUND

Assessing quality of life (QoL) in older people with cognitive impairment is a challenge. There is no consensus on the best tool, but a short, user-friendly scale is advised.

OBJECTIVE

This study aimed to assess the psychometric properties of the self-reported and generic EQ-5D (including the EQ index and EQ visual analog scale [VAS]) in community-dwelling older adults with cognitive impairment.

METHODS

Cross-sectional study analyzing the feasibility, acceptability, reliability, and validity of the EQ-5D based on 188 self-administered questionnaires in a sample of community-dwelling older adults with Mini-Mental State Examination (MMSE) scores of 10 to 24 points.

RESULTS

The EQ index was 0.69 (±0.27) and the EQ VAS was 63.8 (±28.54). Adequate measurement properties were found in acceptability and feasibility. Cronbach's alpha was 0.69. Good validity was observed in the correlation of each dimension of the EQ-5D with geriatric assessment scales. Higher validity was observed for the EQ index compared to the EQ VAS.

CONCLUSION

The EQ-5D scale could be a good tool for assessing health-related QoL in community-dwelling older adults with cognitive impairment, though it is necessary to assess the dimensions and the EQ index.

Promotion of Healthy Aging Within a Community Center Through Behavior Change: Health and Fitness Findings From the AgeWell Pilot Randomized Controlled Trial

The purpose of this randomized controlled trial was to determine if behavior change through individual goal setting (GS) could promote healthy aging, including health and fitness benefits in older adults who attended a community "AgeWell" Center for 12 months. Seventy-five older adults were randomly allocated to either a control or a GS group. Health outcomes were measured at baseline and after 12 months of the participants' having access to the exception of Agewell Center facilities. The findings demonstrate that participation in the Center in itself was beneficial, with improved body composition and reduced cardiovascular risk in both groups (p < .05), and that this kind of community-based resource offers valuable potential for promoting protective behaviors and reducing health risk. However, a specific focus on identifying individual behavior change goals was required in order to achieve increased activity engagement (p < .05) and to bring about more substantial improvements in a range of health, diet, and physical function measures (p < .05).

Level of agreement between adolescents' self-assessment and parent proxy report of health-related quality of life in adolescents with sickle cell disease

BACKGROUND

We aim to assess the levels of agreement between parents, as proxies, and Jamaican adolescents living with sickle cell disease (SCD) in the reporting of the adolescent's quality of life.

PROCEDURES

This cross-sectional study assessed 102 patient/proxy pairs on quality of life of adolescents with SCD using the PedsQL-SCD module. The level of agreement among pairs was assessed starting with broad group-level approaches (the Wilcoxon signed-rank test augmented by exploring percentage agreement) tapering to individual-level approaches (intraclass correlation coefficients [ICCs] supplemented with Bland-Altman plots).

RESULTS

Most patients (76.5%) had homozygous SS disease (45.1% females; mean age 15.2 ± 1.5 years). Median total pediatric quality of life (PedsQL) scores were 79.1 (adolescent report) and 80.2 (parental report) (P = .60). There were 11.8% underestimation and 12.7% overestimation of overall health-related quality of life (HRQOL) by parents. The highest perfect agreement existed on the "pain and hurt" domain for both male and female adolescents (85.7% and 84.4%, respectively). Overestimation was highest on the "social communication" domain for both male and female adolescents (19.6% and 34.8%, respectively). Parents exhibited good agreement on total PedsQL scores in male adolescents (ICC = 0.70), but moderate agreement (ICC = 0.43) in female adolescents. Generally, parents underestimated their male child's functioning and overestimated the female child's functioning on the various domains.

CONCLUSIONS

Parents and adolescents exhibit fair agreement in assessment of the adolescent's overall HRQOL but differ on subjective domains. Agreement varies by sex of the affected teen where girls' HRQOL is generally overestimated by the parental proxy. Interventions to improve parents' understanding of their children's psychosocial needs are needed.

Long-Term Care Quality-of-Life Scale utility in community home care

This study aimed to test the utility of the Long-Term Care Quality-of-Life assessment scale within community home care contexts and to compare the scale against the World Health Organization Quality-of-Life scale in terms of reliability and validity. Both scales were administered concurrently to 109 older adults receiving home care. Analysis revealed the Long-Term Care Quality-of-Life scale to have good test-retest reliability, modest but acceptable internal consistency, and pairwise comparison between the Long-Term Care Quality-of-Life and World Health Organization Quality-of-Life scales' scores suggesting moderate-to-strong correlation of criterion validity and comparability between scales. The results showed that the assessment of individual perceptions of life quality within home care contexts can be monitored and recorded, and that Long-Term Care Quality-of-Life scale monitoring in home and residential care can identify opportunities for quality-of-life support and care continuity, even with transitions between care services and systems. The implications of the present study lie in having access to a validated quality-of-life assessment scale that can be used across care contexts to support evidence-based practice, continuity of care, and acknowledgement of individual circumstances in services and care planning.

Health-related quality of life in adults undergoing transthoracic device closure of ventricular septal defect

Objective

To evaluate the health-related quality of life (HRQoL) of adult patients who underwent transthoracic device closure of ventricular septal defect (VSD).

Methods

During the perioperative and postoperative period, a standard scale involving eight dimensions was used to analyze the HRQoL of 85 adult patients who underwent thoracic device closure of VSD and 80 healthy adults located locally were randomly selected as the control group in our center.

Results

A total of 80 patients’ and 80 healthy adults’ questionnaires were received with complete feedback. Out of all of the items that were investigated, postoperative patients experienced better feelings in some dimensions than the control group. Postoperative feedback was also better than preoperative feedback in some dimensions. In the comparison of the subgroups of these patients, the scores of the elderly were lower than those of the young in most dimensions. Males had more positive feedback in two aspects (“role-physical” (p = 0.01) and “vitality” (p = 0.003)), whereas unmarried people seemed to have poor emotional responses (“role-emotional” (p < 0.01) and “vitality” (p = 0.023)). There was no significant difference in any dimensions except “social functioning” (p < 0.01) between people with different levels of education.

Conclusions

Most of the adult patients who underwent thoracic closure of VSD felt that they could lead a normal life. They seemed to have reasonably normal psychosocial responses compared to healthy controls. Many patients even though their HRQoL was better than healthy individuals.

Relative Association of Multi-Level Supportive Environments on Poor Health among Older Adults

Background: The aging of the United States population poses significant challenges to American healthcare and informal caregiving systems. Additional research is needed to understand how health promotion programs and policies based on a socio-ecological perspective impact the health and well-being of older persons. The purpose of this study was to investigate personal characteristics and supportive environments associated with poor health among older individuals aged 65 and over. Methods: This study used a cross-sectional design and was guided by a conceptual framework developed by the authors to depict the relationship between personal characteristics and environments associated with poor health status. Environment types included in this study were family, home, financial, neighborhood, and healthcare. The sample was comprised of 1319 adults aged 65 years and older residing in Central Texas. From a random selection of households, participants were administered a mail-based survey created by a community collaborative effort. Descriptive statistics and three binary logistic regression models were fitted to examine associations with poor health status (i.e., physical, mental, and combined physical/mental). Results: Two personal characteristics (number of chronic conditions and educational level) were consistently related (p < 0.05) to health outcomes. Supportive family, home, financial, neighborhood, and health care environmental factors were shown to be related (p < 0.05) to various aspects of physical or mental health outcomes. Conclusions: Multidimensional factors including personal characteristics and protective environments are related to health status among older individuals. The unique roles of each environment can help inform public health interventions to create and enhance support for older adults to engage in healthful activities and improve their physical and mental health.

Chronic symptoms in a representative sample of community-dwelling older people: a cross-sectional study in Switzerland

OBJECTIVES

The burden of multiple diagnoses is well documented in older people, but less is known about chronic symptoms, many of which are even not brought to medical attention. This study aimed to determine the prevalence of chronic symptoms, their relationships with disability in basic activities of daily living (BADL) and quality of life (QoL), and their public health impact.

DESIGN

A large cross-sectional population-based study.

SETTING

Community in 2 regions of French-speaking Switzerland.

PARTICIPANTS

Community-dwelling older adults aged 68 years and older in 2011 (N=5300).

OUTCOMES

Disability in BADL defined as difficulty or help needed with any of dressing, bathing, eating, getting in/out of bed or an arm chair, and using the toilet. Overall QoL dichotomised as favourable (ie, excellent or very good) or unfavourable (ie, good, fair or poor). Disturbance by any of the following 14 chronic symptoms for at least 6 months: joint pain, back pain, chest pain, dyspnoea, persistent cough, swollen legs, memory gaps, difficulty concentrating, difficulty making decisions, dizziness/vertigo, skin problems, stomach/intestine problems, urinary incontinence and impaired sexual life.

RESULTS

Only 17.1% of participants did not report being disturbed by any of these chronic symptoms. Weighted prevalence ranged from 3.1% (chest pain) to 47.7% (joint pain). Most chronic symptoms were significantly associated with disability in BADL or unfavourable QoL, with substantial gender differences. The number of chronic symptoms was significantly associated with disability in BADL and unfavourable QoL, with gradients suggesting dose-response relationships. Joint pain and back pain had the highest population attributable fractions.

CONCLUSIONS

Chronic symptoms are highly prevalent in older people, and are associated with disability in BADL and unfavourable QoL, particularly when multiple chronic symptoms co-occur. Owing to their high public health impact, musculoskeletal chronic symptoms represent good targets for preventive interventions.