Examination of the Philadelphia Geriatric Morale Scale as a Subjective Quality-of-Life Measure in Elderly Hong Kong Chinese

Systematic review of 29 self-report instruments for assessing quality of life in older adults receiving aged care services

BACKGROUND

Quality of life (QoL) outcomes are used to monitor quality of care for older adults accessing aged care services, yet it remains unclear which QoL instruments best meet older adults', providers' and policymakers' needs. This review aimed to (1) identify QoL instruments used in aged care and describe them in terms of QoL domains measured and logistical details; (2) summarise in which aged care settings the instruments have been used and (3) discuss factors to consider in deciding on the suitability of QoL instruments for use in aged care services.

DESIGN

Systematic review.

DATA SOURCES

MEDLINE, EMBASE, PsycINFO, Cochrane Library and CINAHL from inception to 2021.

ELIGIBILITY CRITERIA

Instruments were included if they were designed for adults (>18 years), available in English, been applied in a peer-reviewed research study examining QoL outcomes in adults >65 years accessing aged care (including home/social care, residential/long-term care) and had reported psychometrics.

DATA EXTRACTION AND SYNTHESIS

Two researchers independently reviewed the measures and extracted the data. Data synthesis was performed via narrative review of eligible instruments.

RESULTS

292 articles reporting on 29 QoL instruments were included. Eight domains of QoL were addressed: physical health, mental health, emotional state, social connection, environment, autonomy and overall QoL. The period between 1990 and 2000 produced the greatest number of newly developed instruments. The EuroQoL-5 Dimensions (EQ-5D) and Short Form-series were used across multiple aged care contexts including home and residential care. More recent instruments (eg, ICEpop CAPability measure for Older people (ICECAP-O) and Adult Social Care Outcomes Toolkit (ASCOT)) tend to capture emotional sentiment towards personal circumstances and higher order care needs, in comparison with more established instruments (eg, EQ-5D) which are largely focused on health status.

CONCLUSIONS

A comprehensive list of QoL instruments and their characteristics is provided to inform instrument choice for use in research or for care quality assurance in aged care settings, depending on needs and interests of users.

Scaling Down the PGCM Scale to Assess Views on Ageing More Efficiently: Finding a New Alternative

The aim of the study is to present a new and efficient way of measuring the quality of life among older populations, with special attention to morale, positive outlook on life and ageing. The measure is based on the Philadelphia Geriatric Center Morale Scale (PGCM), originally consisting of 22 items. The growing numbers and proportions of older people among European populations has increased the need to obtain more reliable data on their needs, values, life experiences and overall quality of life. Using data from six surveys conducted in the Czech Republic, we have formulated a three-item positive outlook on life and ageing (POLA) scale. Our analyses are divided into three steps: (1) constructing the scale and testing its internal consistency; (2) testing the scale's external validity using mean comparisons and correlation coefficients; and (3) determining the factors affecting a positive outlook on later life, such as gender and education. We have confirmed that the three-item approach to measuring positive outlook on ageing as a part of morale is highly applicable to surveys, producing compelling results in assessing important quality-of-life sub-concepts, such as subjective health, subjective age, and loneliness.

Benefits of Grandparental Caregiving in Chinese Older Adults: Reduced Lonely Dissatisfaction as a Mediator

Objective

The purpose of the present study is twofold: (1) to investigate the differences in terms of physical and mental health between those who provide grandparental care and those who do not and (2) to explore the mechanism that connects grandparental caregiving and health-related outcomes.

Methods

Two studies (a cross-sectional and a short-term longitudinal follow-up) were conducted. The cross-sectional study (Study 1) examined 148 older adults who provided grandparental care and another 150 older adults who did not. A small longitudinal follow-up study (Study 2) was conducted among 102 older adults randomly selected from Study 1, of which 52 were older adults who provided grandparental care, and another 50 older adults were those who did not. Health status (measured by SF-36), lonely dissatisfaction (measured by Lonely Dissatisfaction Subscale of PGC-MS), and cognitive functions (measured by subscales of WAIS) as well as demographics were measured in both studies.

Results

Results of both the cross-sectional and longitudinal studies showed that, compared with older adults who did not provide grandparental care, those providing grandparental care had significantly better physical and mental health as well as reduced lonely dissatisfaction. Further path analysis showed that lonely dissatisfaction mediated the association between providing grandparental care and enhancement in functions such that providing grandparental care could reduce lonely dissatisfaction, which, in turn, could improve their physical and mental health even after controlling for their cognitive functions.

Discussion

These results suggest that providing grandparental care can improve older adults’ physical and mental health through reduced lonely dissatisfaction.

Environment patterns and mental health of older adults in long-term care facilities: the role of activity profiles

Objectives: This study adopts the International Classification of Functioning, Disability and Health (ICF) model to determine extent to which the clustered patterns of long-term care (LTC) environment and activity participation are associated with older residents' mental health. Method: This study enrolled a stratified equal probability sample of 634 older residents in 155 LTC institutions in Taiwan. Latent profile analysis and latent class analysis were conducted to explore the profiles for environment and activity participation. Multilevel modeling was performed to elucidate the hypothesized relationships. Results: Three environment profiles (Low-, Moderate-, and High-Support Environment) based on physical, social, and attitudinal environment domains and two activity profiles (Low- and High-Activity Participation) across seven activity domains were identified. Compared to the Low-Support class, older adults in the Moderate- and High-Support Environment classes had better mental health. Older residents in those two classes were more likely to be in the "High Activity Participation" class, which in turn, exhibited better mental health. Conclusion: Environment and activity participation directly relate to older residents' mental health. Activity participation also mediates the link between environment and mental health. A combination of enhanced physical, social, and attitudinal environments, and continual engagement in various activities may optimize older LTC residents' mental health.

Future Time Perspective and Well-Being in Chinese Older Adults: Moderating Role of Age Stereotypes

Through this cross-sectional study, we aimed to examine the association between future time perspective (FTP) and well-being among older adults, with age stereotypes as a moderator. The participants, 333 Chinese older adults (60-88 years), completed measures related to FTP, age stereotypes, and well-being. The results showed that opportunity and limitation emerged as two subcomponents of FTP, and their effects on well-being depended on older adults' negative age stereotypes. Specifically, for older adults holding less negative age stereotypes, FTP-opportunity and FTP-limitation had a positive effect on well-being, whereas for older adults holding more negative age stereotypes, FTP-opportunity's positive effect became stronger and FTP-limitation's positive effect became weaker and even detrimental. These results indicate that certain qualifiers should be taken into account when considering the relationship between FTP and well-being. These findings contribute to the theoretical understanding of the role of FTP in older adults' well-being.

Gerontechnology acceptance by elderly Hong Kong Chinese: a senior technology acceptance model (STAM)

The purpose of this study was to develop and test a senior technology acceptance model (STAM) aimed at understanding the acceptance of gerontechnology by older Hong Kong Chinese people. The proposed STAM extended previous technology acceptance models and theories by adding age-related health and ability characteristics of older people. The proposed STAM was empirically tested using a cross-sectional questionnaire survey with a sample of 1012 seniors aged 55 and over in Hong Kong. The result showed that STAM was strongly supported and could explain 68% of the variance in the use of gerontechnology. For older Hong Kong Chinese, individual attributes, which include age, gender, education, gerontechnology self-efficacy and anxiety, and health and ability characteristics, as well as facilitating conditions explicitly and directly affected technology acceptance. These were better predictors of gerontechnology usage behaviour (UB) than the conventionally used attitudinal factors (usefulness and ease of use).

Quality of life of older people in China: a systematic review

The quality of life (QoL) of older people is of increasing interest in China, due to its ageing population. A systematic review of published QoL studies was undertaken to examine different measurements and related factors of QoL of older people in China. Papers were identified by searching the following electronic databases: Web of Science, PsycINFO, MEDLINE, PubMed, CINAHL, China Academic Journal and VIP Database for Chinese Technical Periodicals. Fifteen studies were included in the review, using eight different QoL measurement tools. Health status, psychological well-being, social well-being, housing and socio-demographic factors were identified as important related factors of QoL. Further studies are needed using valid measurement tools to explore more factors, especially culturally specific contributors, to the QoL of older people.

Assessment of factors influencing morale in the elderly

Background

We examined the relationship between morale measured by the Philadelphia Geriatric Morale Scale (PGC) and disability, social support, religiosity, and personality traits. Instruments predicting morale were then tested against PGC domains.

Methods

The study utilized a cross-sectional survey with a multistage cluster sampling design. Instruments used were disability (disease burden; WHO Disability Score-II, WHODAS-II), social support (Duke Social Support Scale, DUSOCS; Lubben Social Network Scale, LSNS-6; Medical Outcomes Study Social Support Survey, MOS-SSS), religiosity (Revised Intrinsic-Extrinsic Religious Orientation Scale, I/E-R), and personality (Ten-Item Personality Inventory, TIPI). These were plotted as bar charts against PGC, resolved with one-way ANOVA and Kruskal-Wallis tests, then corrected for multiple comparisons. This process was repeated with PGC domains. Contribution of factors was modeled using population attributable risk (PAR) and odds ratios. Effect of confounders such as gender, age, and ethnicity were checked using binary logistic regression.

Results

All instruments showed clear relationships with PGC, with WHODAS-II and DUSOCS performing well (ANOVA p<0.001). For PGC domains, attitude toward aging and lonely dissatisfaction trended together, while agitation did not. PAR, odds ratios, and Exp(β) were disability (WHODAS-II: 28.5%, 3.8, 2.8), social support (DUSOCS: 28.0%, 3.4, 2.2), religiosity (I/E-R: 21.6%, 3.2, 2.1), and personality (TIPI: 27.9%, 3.6, 2.4). Combined PAR was 70.9%.

Conclusions

Disability, social support, religiosity, and personality strongly influence morale in the elderly. WHODAS-II and DUSOCS perform best in measuring disability and social support respectively.

Subjective well-being, social support, and age-related functioning among the very old in China

OBJECTIVE

Previous research has suggested that social support and functional status influence the subjective well-being of the elderly. However, few studies have investigated whether these associations influence well-being in the very old.

METHODS

In this population-based, cross-sectional study, 1401 persons aged 90 years or over were located in Du Jiang Yan city, Sichuan, China. Among them 732 were willing to participate and provided data on a battery of standardized questionnaire inventories. The 23-item Philadelphia Geriatric Center Morale Scale (PGCMS) was examined as an index of subjective well-being. Functional status was assessed using the physical self-maintenance scale (PSMS) and the instrumental activities of daily living (IADL) scales. The mini-mental state examination (MMSE) was used to measure cognitive function. Social support was assessed using the Family Adaptation, Partnership, Growth, Affection, and Resolve (APGAR) scale and the social support requirement scale (SSRS).

RESULTS

The mean age was 93.7 +/- 3.4 years for the participants, of whom 68% were female. PGCMS total scores were significantly correlated with the Family APGAR and Objective Support subscale of the SSRS, as well as with scores on the MMSE and PSMS scales. However, in a multiple regression analysis, only MMSE and Family APGAR scores were independent predictors of PGCMS scores.

CONCLUSION

Both social support from family members and cognitive function appear to be key factors associated with quality of life among the very old in China. Further research is needed among very old populations to confirm the importance of these variables and to examine potential cross-cultural differences.

A structural equation modelling approach to the complex path from postural stability to morale in elderly people with fear of falling

PURPOSE

To test a model of the path from Activity Limitation (postural instability) to participation (morale), taking account of the influence of psychological variables of appraisal, emotion and self-efficacy. Also to attempt to define whether elderly people with fear of falling are fearful because they are posturally unstable or because they are generally anxious.

METHOD

Elderly inpatients (n = 153, age: 67-95, 31% men) were assessed shortly before their discharge home. They were invited to complete tests of postural stability and questionnaires about consequences of falling, previous experience of falls, subjective unsteadiness, emotional state, balance confidence, concern and fear about falling and morale. Results were treated with Pearson correlations and structural equation modelling.

RESULTS

All variables related to morale, the highest correlation being with anxiety and depression. However, there was no direct path from postural instability to morale. Balance confidence and fear of falling formed separate end points, neither affecting morale.

CONCLUSIONS

Morale alone is not an adequate outcome of rehabilitation. Increased balance confidence and reduced fear of falling need to be addressed in their own right and assessed independently of morale in elderly rehabilitation.

Stability of the Philadelphia Geriatric Center Morale Scale: A Multidimensional Item Response Model and Rasch Analysis

The purpose of this study was to explore the longitudinal structural and measurement invariance of the 17-item Philadelphia Geriatric Center Morale Scale (PGCMS) using a multidimensional item response model and the unidimensional Rasch model in contrast to prior work employing classical test theory. Participants ( n = 177) were assigned to three interventions and assessed at three time points. The structural analyses found that a 3-factor model fit better than a 1-factor or a 2-factor model using the Akaike information criterion (AIC) and Schwartz’s Bayesian information criterion (BIC) though not with the AICPC or the BIC PC. With respect to item fit, differential item functioning (DIF) and correlation of item logit positions, the PGCMS was quite stable. However, Items 4 and 5 were problematic in terms of fit. The internal consistency reliabilities of three factors were also relatively lower than desirable at one point and adequate at others.

Philadelphia Geriatric Morale Scale in essential tremor: a population-based study in three Spanish communities

Essential tremor (ET) is associated with both functional disability and depression. Each could contribute to a poor sense of well-being and low morale. We hypothesized that morale would be lower in ET cases than controls. Using a population-based, cross-sectional design, morale was assessed in 187 ET cases and 561 matched controls living in three communities in central Spain using the Philadelphia Geriatric Center Morale Scale (PGCMS) (range = 0 [low morale]-17), which included three-dimensions of psychological well-being: agitation, lonely dissatisfaction, and attitude toward own aging. The PGCMS score was lower in ET cases than controls (9.41 +/- 3.21 vs. 10.39 +/- 2.92, P < 0.001), as were the Agitation subscore (3.17 +/- 1.71 vs. 3.78 +/- 1.67, P< 0.001) and Lonely Dissatisfaction subscore (3.75 +/- 1.34 vs. 4.02 +/- 1.24, P < 0.05). Nearly one-half of the ET cases were classified as having low morale compared with only one-third of controls (P = 0.006). In a linear regression analysis adjusting for demographic factors and multiple comorbid conditions, ET cases had a lower log PGCMS score than controls (P < 0.001). Exclusion of participants on antidepressant medication did not change the results. Our results indicate that morale is significantly lower in community-dwelling ET cases than in matched controls. This lower morale could in part be a proxy for mild, untreated depression. It therefore seems important to detect and then possibly treat this problem to improve the psychological well-being of patients with this disease.

Psychological well-being is an independent predictor of falling in an 8-year follow-up of older adults

A population-based sample (N = 787) was followed for 8 years and assessed three times on measures of well-being (depressive symptoms, morale, and control) and fall history. Marginal models assessed the association between baseline well-being measures and falling. Random effects models assessed change in well-being indicators as well as change in fall rate over 8 years. After adjustment for sociodemographics, psychotropic medication, health, and sensorimotor function, our results showed that depressive symptoms, control, and morale were risk factors for subsequent falling, and an increase in depressive symptoms or a reduction in morale was associated with an increasing fall rate. We conclude that the three well-being measures are independently associated with falling and need to be considered in fall-risk assessments and population-based prevention and intervention strategies.

Depression is the predominant factor contributing to morale as measured by the Philadelphia Geriatric Morale Scale in elderly Chinese aged 70 years and over

OBJECTIVE

To examine factors contributing to the total Philadelphia Geriatric Morale Scale (PGMS) and its two subscales: reconciled ageing and unstrained affect.

METHOD

The PGMS was administered to 759 community-living subjects aged 70 years and over. Information regarding socioeconomic status, health conditions, sensory impairment, physical symptoms, social support, activities of daily living as measured by the Barthel Index, life satisfaction, and the Geriatric Depression Score, was collected. Associations between these factors and PGMS and its subscale were examined using univariate analysis (Mann-Whitney; Kruskal-Wallis tests), and multivariate analysis using the classification and regression tree (CART) method.

RESULTS

Gender, old age, physical, socioeconomic and social factors were significantly associated with PGMS. There was a strong correlation with GDS (r = 0.77, p < 0.001). In the CART analysis, for both subscales and the total score, GDS was the predominant factor contributing to the score. Other factors include self perception of health, enough expenses, overall satisfaction with life, gender, and constipation.

DISCUSSION

The PGMS and GDS are closely related. In addition to the GDS, health perception, life satisfaction, and adequate finance were factors contributing to quality of life in elderly Hong Kong Chinese.