Measuring health-related quality of life in older patient populations: a review of current approaches

Economic evaluation of health promotion interventions for older people: do applied economic studies meet the methodological challenges?

BACKGROUND

In the light of demographic developments health promotion interventions for older people are gaining importance. In addition to methodological challenges arising from the economic evaluation of health promotion interventions in general, there are specific methodological problems for the particular target group of older people. There are especially four main methodological challenges that are discussed in the literature. They concern measurement and valuation of informal caregiving, accounting for productivity costs, effects of unrelated cost in added life years and the inclusion of 'beyond-health' benefits. This paper focuses on the question whether and to what extent specific methodological requirements are actually met in applied health economic evaluations.

METHODS

Following a systematic review of pertinent health economic evaluations, the included studies are analysed on the basis of four assessment criteria that are derived from methodological debates on the economic evaluation of health promotion interventions in general and economic evaluations targeting older people in particular.

RESULTS

Of the 37 studies included in the systematic review, only very few include cost and outcome categories discussed as being of specific relevance to the assessment of health promotion interventions for older people. The few studies that consider these aspects use very heterogeneous methods, thus there is no common methodological standard.

CONCLUSION

There is a strong need for the development of guidelines to achieve better comparability and to include cost categories and outcomes that are relevant for older people. Disregarding these methodological obstacles could implicitly lead to discrimination against the elderly in terms of health promotion and disease prevention and, hence, an age-based rationing of public health care.

Factors associated with health-related quality of life in stable ambulatory congestive heart failure patients: Systematic review

Background Since improved treatment of congestive heart failure has resulted in decreased mortality and hospitalisation rates, increasing self-perceived health-related quality of life (HRQoL) has become a major goal of congestive heart failure treatment. However, an overview on predictieve factors of HRQoL is currently lacking in literature. Purpose The aim of this study was to identify key factors associated with HRQoL in stable ambulatory patients with congestive heart failure. Methods A systematic review was performed. MEDLINE, Web of Science and Embase were searched for the following combination of terms: heart failure, quality of life, health perception or functional status between the period 2000 and February 2017. Literature screening was done by two independent reviewers. Results Thirty-five studies out of 8374 titles were included for quality appraisal, of which 29 were selected for further data extraction. Four distinct categories grouping different types of variables were identified: socio-demographic characteristics, clinical characteristics, health and health behaviour, and care provider characteristics. Within the above-mentioned categories the presence of depressive symptoms was most consistently related to a worse HRQoL, followed by a higher New York Heart Association functional class, younger age and female gender. Conclusion Through a systematic literature search, factors associated with HRQoL among congestive heart failure patients were investigated. Age, gender, New York Heart Association functional class and depressive symptoms are the most consistent variables explaining the variance in HRQoL in patients with congestive heart failure. These findings are partly in line with previous research on predictors for hard endpoints in patients with congestive heart failure.

Examining the Effects of Age on Health Outcomes of Chronic Obstructive Pulmonary Disease: Results From the Genetic Epidemiology of Chronic Obstructive Pulmonary Disease Study and Evaluation of Chronic Obstructive Pulmonary Disease Longitudinally to Identify Predictive Surrogate Endpoints Cohorts

RATIONALE

The prevalence of chronic obstructive pulmonary disease (COPD) and its associated comorbidities increase with age. However, little is understood about differences in the disease in patients over 65 years of age compared with younger patients.

OBJECTIVES

To determine disease characteristics of COPD and its impact in older patients compared with younger patients.

METHODS

We examined baseline characteristics of patients with COPD (global obstructive lung disease stage II-IV) in 2 large cohorts: Genetic Epidemiology of COPD Study (COPDGene) and Evaluation of COPD Longitudinally to Identify Predictive Surrogate Endpoints (ECLIPSE). We compared demographics, indices of disease severity, prevalence of comorbidities, exacerbation frequency, and quality of life scores in patients ≥65 years of age vs patients <65 years of age. We also tested for associations of age with disease characteristics and health outcomes.

RESULTS

In the COPDGene cohort, older patients (n = 1663) had more severe disease as measured by forced expiratory volume in 1 second (1.22 vs 1.52 L, P < .001), use of long-term oxygen therapy (35% vs 22%, P < .001), 6-minute walk distance (355 vs 375 m, P < .001), and radiographic evidence of emphysema (14% vs 8%, P < .001) and air trapping (47% vs 36%, P < .001) and were more likely to have comorbidities compared with younger patients (n = 2027). Similarly, in the ECLIPSE cohort, older patients (n = 1030) had lower forced expiratory volume in 1 second (1.22 vs 1.34 L, P < .001), greater use of long-term oxygen therapy (7% vs 5%, P = .02), shorter 6- minute walk distance (360 vs 389 m, P < .001), and more radiographic evidence of emphysema (17% vs 14%, P = .009) than younger patients (n = 1131). In adjusted analyses of both cohorts, older age was associated with decreased frequency of exacerbations [odds ratio = 0.52, 95% confidence interval (CI) = 0.43-0.64 in COPDGene, odds ratio = 0.79, 95% CI = 0.64-0.99 in ECLIPSE] and a better quality of life (lower St. Georges respiratory questionnaire score) (β = -8.7, 95% CI = -10.0 to -7.4 in COPDGene, β = -4.4, 95% CI = -6.1 to -3.2 in ECLIPSE).

CONCLUSIONS

Despite greater severity of illness, older patients with COPD had better quality of life and reported fewer exacerbations than younger patients. Although this observation needs to be explored further, it may be related to the fact that older patients change their expectations and learn to adapt to their disease.

Methodological issues in measuring subjective well-being and quality-of-life: Applications to assessment of affect in older, chronically and cognitively impaired, ethnically diverse groups using the Feeling Tone Questionnaire

Quality of life assessment includes measurement of positive affect. Methods artifacts associated with positively and negatively worded items can manifest as negative items loading on a second factor, despite the conceptual view that the items are measuring one underlying latent construct. Negatively worded items may elicit biased responses. Additionally, item-level response bias across ethnically diverse groups may compromise group comparisons. The aim was to illustrate methodological approaches to examining method factors and measurement equivalence in an affect measure with 9 positively and 7 negatively worded items: The Feeling Tone Questionnaire (FTQ). The sample included 4,960 non-Hispanic White, 1,144 non-Hispanic Black, and 517 Hispanic community and institutional residents receiving long-term supportive services. The mean age was 82 (s.d.=11.0); 73% were female. Two thirds were cognitively impaired. Methods effects were assessed using confirmatory factor analyses (CFA), and reliability with McDonald's omega and item response theory (IRT) generated estimates. Measurement equivalence was examined using IRT-based Wald tests. Methods effects associated with negatively worded items were observed; these provided little IRT information, and as a composite evidenced lower reliability. Both 13 and 9 item positive affect scales performed well in terms of model fit, reliability, IRT information, and evidenced little differential item functioning of high magnitude or impact. Both CFA and IRT approaches provided complementary methodological information about scale performance. The 9-item affect scale based on the FTQ can be recommended as a brief quality-of-life measure among frail and cognitively impaired individuals in palliative and long-term care settings.

Lifetime traumatic events, health-related quality of life, and satisfaction with life in older adults

PURPOSES

The aims were to assess the association between lifetime traumatic events and post-traumatic stress syndrome (PTSS) and health-related quality of life (HRQOL) and satisfaction with life stratified by gender among a community-dwelling sample of older adults.

METHODS

Data used came from the ESA-Services study (2011-2013) and included a large convenience sample of 1811 older adults. Traumatic events were measured using a list of 14 events. PTSS was measured using the Impact of Event Scale-Revised. HRQOL and life satisfaction were measured with the EQ-5D-3L and the Satisfaction With Life Scale. Multivariate regression analyses were used to assess the association between traumatic events, PTSS, and quality of life.

RESULTS

Respondents had a mean age of 73.90 years (SD: 6.13, range 65-97). Our results showed that exposure to violence (OR 4.88, CI 2.72-8.77), an accident (OR 2.33, CI 1.29-4.22), and sexual abuse (OR 2.26 CI 1.17-4.37) was associated with PTSS only in women. No traumatic event was associated only in men. The interaction between gender and exposure to violence and life-threatening disease of a close one was significant. Experiencing violence (β = -0.04, p < 0.01), a natural disaster (β = -0.04, p = 0.02), a life-threatening disease (β = -0.04, p < 0.01), and sexual abuse (β = -0.04, p < 0.01) were associated with a lower HRQOL only in women. No traumatic event was associated in men. Interactions between event and gender were significant for natural disaster, life-threatening disease of a close one, sexual abuse, and other type of traumatic events. A life-threatening disease (β = -0.90, p < 0.01) was associated with a reduced life satisfaction only in men and the exposure of violence (β = -1.18, p < 0.01) was associated with lower life satisfaction in women.

CONCLUSION

Our study could help healthcare professionals to identify and monitor traumatic events that are at higher risk to be associated with PTSS and a lower quality of life for older men and women.

Combined Impact of Traditional and Non-Traditional Healthy Behaviors on Health-Related Quality of Life: A Prospective Study in Older Adults

Combined exposure to several healthy behaviors (HB) is associated with reduced mortality in older adults but its impact on health-related quality of life (HRQL) is uncertain. This is a cohort study of 2,388 individuals aged ≥60 recruited in 2000–2001, whose data were updated in 2003 and 2009. At baseline, participants reported both traditional HB (non-smoking, being very or moderately active, healthy diet) and non-traditional HB (sleeping 7–8 h/d, being seated <8 h/d, and seeing friends every day). HRQL was measured with the SF-36 questionnaire at baseline, in 2003 (short-term) and in 2009 (long-term); a higher score on the SF-36 represents better HRQL. Linear regression models were used to assess the association between HB at baseline and HRQL in 2003 and 2009, with adjustment for the main confounders including baseline HRQL. In the short-term, being physically active, sleeping 7–8 h/d, and being seated <8 h/d was associated with better HRQL. Compared to having ≤1 of these HB, the β (95% confidence interval) for the score on the physical component summary of the SF-36 in 2003 was 1.42 (0.52–2.33) for 2 HB, and 2.06 (1.09–3.03) for 3 HB, p-trend <0.001. Corresponding figures for the mental component summary score were 1.89 (0.58–3.21) for 2 HB and 3.35 (1.95–4.76) for 3 HB, p-trend <0.001. Non-smoking, a healthy diet or seeing friends did not show an association with HRQL. In the long-term, being physically active was the only HB associated with better physical HRQL. As a conclusion, a greater number of HB, particularly more physical activity, adequate sleep duration, and sitting less, were associated with better short-term HRQL in older adults. However, in the long-term, being physically active was the only HB associated with better physical HRQL.

The effectiveness of individual rehabilitation on health status in patients with heart failure: A quasi-experimental study

Patients with heart failure (HF) live with a serious disease, and need long-term rehabilitation care. Elements in rehabilitation for patients with HF are based on the recommendations from the European Society of Cardiology and focuses on self-care and adherence in general. The aim of this study is to test the effect of individually prepared rehabilitation plans measured on health status (HS). The study design is quasi-experimental. Patients in the control group follow the conventional rehabilitation. For the patients in the intervention group. an individual rehabilitation plan was prepared and followed up by telephone after 4 and 12 weeks. For all patients, HS was measured with Short Form-36. One hundred sixty-two patients are included in the study, of which 137 (84.6%) consented. There were no differences in HS before and after the intervention. There are no significant differences by use of a systematically prepared intervention compared with usual care for patients with HF measured on HS 3 months after discharge from the outpatient clinic.

Post-traumatic stress syndrome in a large sample of older adults: determinants and quality of life

OBJECTIVES

The aims of this study are to assess in a sample of older adults consulting in primary care practices the determinants and quality of life associated with post-traumatic stress syndrome (PTSS).

METHOD

Data used came from a large sample of 1765 community-dwelling older adults who were waiting to receive health services in primary care clinics in the province of Quebec. PTSS was measured with the PTSS scale. Socio-demographic and clinical characteristics were used as potential determinants of PTSS. Quality of life was measured with the EuroQol-5D-3L (EQ-5D-3L) EQ-Visual Analog Scale and the Satisfaction With Your Life Scale. Multivariate logistic and linear regression models were used to study the presence of PTSS and different measures of health-related quality of life and quality of life as a function of study variables.

RESULTS

The six-month prevalence of PTSS was 11.0%. PTSS was associated with age, marital status, number of chronic disorders and the presence of an anxiety disorder. PTSS was also associated with the EQ-5D-3L and the Satisfaction with Your Life Scale.

CONCLUSION

PTSS is prevalent in patients consulting in primary care practices. Primary care physicians should be aware that PTSS is also associated with a decrease in quality of life, which can further negatively impact health status.

Economic evaluation of health promotion for older people-methodological problems and challenges

BACKGROUND

The support of health promotion activities for older people gains societal relevance in terms of enhancing the health and well-being of older people with a view to the efficient use of financial resources in the healthcare sector. Health economic evaluations have become an important instrument to support decision-making processes in many countries. Sound evidence on the cost-effectiveness of health promotion activities would encourage support for the implementation of health promotion activities for older people. This debate article discusses to what extent economic evaluation techniques are appropriate to support decision makers in the allocation of resources regarding health promotion activities for older people. We address the problem that the economic evaluation of these interventions is hampered by methodological obstacles that limit comparability, e.g. with economic evaluations of curative measures. Our central objective is to describe and discuss the specific problems and challenges entailed in the economic evaluation of health promotion activities especially for older people with regard to their usefulness for informing decision making processes.

DISCUSSION

Beyond general problems concerning the economic evaluation of health promotion, our discussion focusses on problems that pertain to the analysis of cost and outcomes of health promotion interventions for older people. With regard to costs these are general problems of economic evaluations, namely the actual implementation of a societal perspective, the appropriate measurement and valuation of informal caregiver time, the measurement and valuation of productivity costs and costs incurred in added years of life. The main problems concerning the identification and measurement of outcomes are related to the identification of outcome parameters that, firstly, adequately reflect the broad effects of health promotion interventions, especially social benefits that gain importance for older people, and secondly, ensure a comparability of effects across different age groups. In particular, the limitations of the widely used QALY for older people are discussed and recently developed alternatives are presented.

CONCLUSIONS

The key conclusion of the article is that a comparison of the effects of different health promotion initiatives between different age groups by means of economic evaluation is not recommendable. Taking into account the complex outcomes of health promotion interventions it has to be accepted that the outcomes of these interventions will often not be comparable with clinical interventions and have to be assessed differently.

Multimorbidity in chronic disease: impact on health care resources and costs

Effective and resource-efficient long-term management of multimorbidity is one of the greatest health-related challenges facing patients, health professionals, and society more broadly. The purpose of this review was to provide a synthesis of literature examining multimorbidity and resource utilization, including implications for cost-effectiveness estimates and resource allocation decision making. In summary, previous literature has reported substantially greater, near exponential, increases in health care costs and resource utilization when additional chronic comorbid conditions are present. Increased health care costs have been linked to elevated rates of primary care and specialist physician occasions of service, medication use, emergency department presentations, and hospital admissions (both frequency of admissions and bed days occupied). There is currently a paucity of cost-effectiveness information for chronic disease interventions originating from patient samples with multimorbidity. The scarcity of robust economic evaluations in the field represents a considerable challenge for resource allocation decision making intended to reduce the burden of multimorbidity in resource-constrained health care systems. Nonetheless, the few cost-effectiveness studies that are available provide valuable insight into the potential positive and cost-effective impact that interventions may have among patients with multiple comorbidities. These studies also highlight some of the pragmatic and methodological challenges underlying the conduct of economic evaluations among people who may have advanced age, frailty, and disadvantageous socioeconomic circumstances, and where long-term follow-up may be required to directly observe sustained and measurable health and quality of life benefits. Research in the field has indicated that the impact of multimorbidity on health care costs and resources will likely differ across health systems, regions, disease combinations, and person-specific factors (including social disadvantage and age), which represent important considerations for health service planning. Important priorities for research include economic evaluations of interventions, services, or health system approaches that can remediate the burden of multimorbidity in safe and cost-effective ways.

Czech version of OPQOL-35 questionnaire: the evaluation of the psychometric properties

BACKGROUND

Both prognoses and real demographic trends in developed countries point to the increasing proportion in the population of people above 65 years of age. One of important themes of care for seniors is the assessment of their quality of life. To evaluate the quality of life of seniors three types of tools can be used: general generic tools; generic tools used for the age group of elderly persons; specific tools to detect the quality of life of the elderly who are affected by specific diseases.

METHODS

The second type of tool is represented by the OPQOL - 35 questionnaire (Older People's Quality of Life Questionnaire), which was developed in the UK. It has 35 items and deals with 8 domains of quality of life. With the consent of the author the questionnaire was translated into Czech and verified in a group of 478 seniors aged 60 and above (40 % males, 60 % females). Unlike the British version, the Czech version has seven factors: 1 Role of belief, religion and culture; 2 Health; independence, active life; 3 Financial situation; 4 Family and safe environment; 5 Loneliness; 6 Satisfaction with life; 7 Positive approach to life.

RESULTS

The Czech version has a very good reliability (Cronbach's alpha ranges from .726 to .905). It also has satisfactory validity. The results show that with increasing age and number of health problems the satisfaction of the elderly is declining in all seven domains. Conversely, the degree of autonomy in the way of living is positively associated with the satisfaction of seniors. Old people who live alone at home, are self-sufficient and do not need the help of others, are more satisfied with their quality of life than other seniors (i.e..those who are living with their children, in sheltered accommodation or in homes for the elderly). Single, married seniors and seniors with a partner are happier than the widowed ones.

CONCLUSIONS

The questionnaire gives good guidance for assessing the current state of the quality of life of seniors, changes in quality over time and for targeted interventions as well.

Reliability, validity and clinical correlates of the Quality of Life in Alzheimer's disease (QoL-AD) scale in medical inpatients

Background

There is a lack of standardisation in quality of life (QoL) measurements to be used in older multimorbid patients. An ideal QoL measurement should be reliable, valid, subjective, multidimensional, feasible and generic. We hypothesised that the QoL-AD (Quality of Life in Alzheimer’s Disease) scale could have these properties. Our aim was to determine the psychometric properties and clinical correlations of QoL-AD in a population of elderly, multimorbid medical inpatients.

Methods

QoL-AD was performed in 200 medical inpatients, and available caregivers. Reliability was determined using cronbach’s alpha and corrected item-total correlations. The agreement between patient and proxy ratings were examined using intra-class correlations (ICC). Correlations between QoL-AD and demographic data, comorbidity, cognitive tests, ADL (activities of daily living) and depression were examined. To characterise the underlying constructs of QoL-AD, an exploratory factor analysis was performed.

Results

In total, 199 patients fulfilled the QoL-AD rating, with 139 proxy ratings. Cronbach’s alpha (95 % CI) was 0.74 (0.68–0.79) for patients and 0.86 (0.83–0.90) for proxies. Patient-proxy ICC (95 % CI) was 0.31 (0.16–0.46). Lower QoL was correlated to depression, cognitive impairment, ADL impairment and solitary living, but not with comorbidity. The factor analysis gave a three-factor solution, with factors representing phsyical, social and psychological well-being.

Conclusion

The QoL-AD scale showed some promising properties but more research is needed before it can be recommended in this setting. If replicated, the finding that cognitive impairment, depression and ADL impairment were more associated with lower QoL than somatic comorbidity could have clinical implications for further studies aiming to improve QoL in this population.

Electronic supplementary material

The online version of this article (doi:10.1186/s12955-016-0493-8) contains supplementary material, which is available to authorized users.

Patient-Reported Outcome Measures (PROMS) in patients undergoing heart valve surgery: why should we measure them and which instruments should we use?

Objective

As the population ages, the incidence of heart valve disease (HVD) is increasing. The aim of treatment is to improve prognosis and quality of life. Standard surgical treatment is being superseded by new catheter-based treatments, many of which are as yet unproven. The need for appropriate instruments to measure quality of life in patients receiving treatment for HVD has therefore never been greater.

Methods

In this prospective observational study, a generic instrument, Euroqol, and a disease-specific one (Minnesota Living with Heart Failure Questionnaire—MLHFQ) were, for the first time, formally tested before and after surgery in 84 patients with HVD who completed their treatment. Patients were interviewed on the night before surgery and 6–12 weeks after being discharged. Instruments were tested for validity, reliability, responsiveness, sensitivity and interpretability.

Results

Both Euroqol and MLHFQ registered significant improvements in patients' health. Tests for validity were significantly positive for both Euroqol and MLHFQ. Tests for reliability and responsiveness were very positive for MLHFQ, less so for EQ-5D. There was a moderate ceiling effect in the postoperative Index scores of Euroqol and a moderate floor effect in MLHFQ.

Conclusions

Both instruments together performed very well in assessing the health of patients undergoing surgical treatment of HVD. As the incidence of HVD increases and therapeutic options increase, measurement of PROMS using these two instruments should become a matter of routine.

Reporting of patient-centred outcomes in heart failure trials: are patient preferences being ignored?

Older people often suffer from multiple diseases. Therefore, universal cross-disease outcomes (e.g. functional status, quality of life, overall survival) are more relevant than disease-specific outcomes, and a range of potential outcomes are needed for medical decision-making. To assess how patient-relevant outcomes have penetrated randomized controlled trials (RCTs), reporting of these outcomes was reviewed in heart failure trials that included patients with multimorbidity. We systematically reviewed RCTs (Jan 2011–June 2012) and evaluated reported outcomes. Heart failure was chosen as condition of interest as this is common among older patients with multimorbidity. The main outcome was the proportion of RCTs reporting all-cause mortality, all-cause hospital admission, and outcomes in four domains of health, i.e. functional, signs and symptoms, psychological, and social domains. Of the 106 included RCTs, 50 (47 %) reported all-cause mortality and cardiovascular mortality and 29 (27 %) reported all-cause hospitalization and cardiovascular hospitalization. Of all trials, 68 (64 %) measured outcomes in the functional domain, 80 (75 %) in the domain of signs and symptoms, 65 (61 %) in the psychological domain, and 59 (56 %) in the social domain. Disease-specific instruments were more often used than non-disease-specific instruments. This review shows increasing attention for more patient-relevant outcomes; this is promising and indicates more awareness of the importance of a variety of outcomes desirable for patients. However, patients’ individual goal attainments were universally absent. For continued progress in patient-centred care, efforts are needed to develop these outcomes, study their merits and pitfalls, and intensify their use in research.

Comprehensively Measuring Health-Related Subjective Well-Being: Dimensionality Analysis for Improved Outcome Assessment in Health Economics

BACKGROUND

Allocation of inevitably limited financial resources for health care requires assessment of an intervention's effectiveness. Interventions likely affect quality of life (QOL) more broadly than is measurable with commonly used health-related QOL utility scales. In line with the World Health Organization's definition of health, a recent Delphi procedure showed that assessment needs to put more emphasis on mental and social dimensions.

OBJECTIVE

To identify the core dimensions of health-related subjective well-being (HR-SWB) for a new, more comprehensive outcome measure.

METHODS

We formulated items for each domain of an initial Delphi-based set of 21 domains of HR-SWB. We tested these items in a large sample (N = 1143) and used dimensionality analyses to find a smaller number of latent factors.

RESULTS

Exploratory factor analysis suggested a five-factor model, which explained 65% of the total variance. Factors related to physical independence, positive affect, negative affect, autonomy, and personal growth. Correlations between the factors ranged from 0.19 to 0.59. A closer inspection of the factors revealed an overlap between the newly identified core dimensions of HR-SWB and the validation scales, but the dimensions of HR-SWB also seemed to reflect additional aspects. This shows that the dimensions of HR-SWB we identified go beyond the existing health-related QOL instruments.

CONCLUSIONS

We identified a set of five key dimensions to be included in a new, comprehensive measure of HR-SWB that reliably captures these dimensions and fills in the gaps of the existent measures used in economic evaluations.

Association between frailty and quality of life among community-dwelling older people: a systematic review and meta-analysis

BACKGROUND

With growing numbers of older people worldwide, improving and maintaining quality of life during the extended years of life are a major focus for healthcare providers and policymakers. Some studies have suggested frailty may be associated with worse quality of life.

OBJECTIVES

To review the associations between frailty and quality of life among community-dwelling older people.

METHODS

A systematic literature search was performed using five databases for cross-sectional and longitudinal studies examining associations between frailty and quality of life among community-dwelling older people published in 2000 or later. Reference lists of relevant studies were also manually searched. Authors were requested for data for a meta-analysis if necessary. Meta-analysis was attempted for studies using the same frailty criteria and quality-of-life instrument. Methodological quality, heterogeneity and publication bias were assessed.

RESULTS

The systematic review identified 5145 studies, among which 11 cross-sectional studies and two longitudinal studies were included in this review. Meta-analysis including four cross-sectional studies using the Fried Phenotype and 36-Item Short Form Health Survey showed that those classified as frail and prefrail had significantly lower mental and physical quality-of-life scores than those classified as non-frail. High heterogeneity and possible publication bias were noted.

CONCLUSIONS

This systematic review and meta-analysis has demonstrated the evidence of a consistent inverse association between frailty/prefrailty and quality of life among community-dwelling older people. Interventions targeted at reducing frailty may have the additional benefit of improving corresponding quality of life. More longitudinal analysis is required to determine this effect.

Improving Health Related Quality of Life and Independence in Community Dwelling Frail Older Adults through a Client-Centred and Activity-Oriented Program. A Pragmatic Randomized Controlled Trial

INTRODUCTION AND AIM

In the ageing society, a considerable part of the older adults are frail. Frailty has a major impact on the individual's quality of life, independence and also on his environment. This study aimed to investigate - as a secondary prevention of disability - the effectiveness of a client-centred and activity-oriented intervention program for frail community living older adults. It was hypothesized that this program could be effective in improving basic Activities of Daily Living (b-ADL) and increasing Health Related Quality of Life (HRQoL).

METHOD

This study was a single blind randomized controlled trial with an intervention and a control group (pre-test-post-test control group design). Analysis of covariance (ANCOVA) was used to compare the outcome across groups with post-test as outcome and baseline values as a covariate. Data were analysed using the intention-to-treat principle.

RESULTS

The intervention group (n = 86) experienced more improvement on b-ADL and HRQoL compared with the control group (n = 82). These effects were statistically significant for the b-ADL index (p = 0.013) and the 'physical subscale pain' (p = 0.049).

DISCUSSION AND CONCLUSION

These positive results can be seen as promising for further development of intervention strategies, although follow-up study should be conducted to determine long term effectiveness.

Improving Health Related Quality of Life and Independence in Community Dwelling Frail Older Adults through a Client-Centred and Activity-Oriented Program. A Pragmatic Randomized Controlled Trial

INTRODUCTION AND AIM

In the ageing society, a considerable part of the older adults are frail. Frailty has a major impact on the individual's quality of life, independence and also on his environment. This study aimed to investigate - as a secondary prevention of disability - the effectiveness of a client-centred and activity-oriented intervention program for frail community living older adults. It was hypothesized that this program could be effective in improving basic Activities of Daily Living (b-ADL) and increasing Health Related Quality of Life (HRQoL).

METHOD

This study was a single blind randomized controlled trial with an intervention and a control group (pre-test-post-test control group design). Analysis of covariance (ANCOVA) was used to compare the outcome across groups with post-test as outcome and baseline values as a covariate. Data were analysed using the intention-to-treat principle.

RESULTS

The intervention group (n = 86) experienced more improvement on b-ADL and HRQoL compared with the control group (n = 82). These effects were statistically significant for the b-ADL index (p = 0.013) and the 'physical subscale pain' (p = 0.049).

DISCUSSION AND CONCLUSION

These positive results can be seen as promising for further development of intervention strategies, although follow-up study should be conducted to determine long term effectiveness.

Cost-utility analysis of case management for frail older people: effects of a randomised controlled trial

BACKGROUND

To evaluate the effects of a case management intervention for frail older people (aged 65+ years) by cost and utility.

MATERIALS AND METHODS

One hundred and fifty-three frail older people living at home were randomly assigned to either an intervention (n = 80) or a control group (n = 73). The 1-year intervention was carried out by nurses and physiotherapists working as case managers, who undertook home visits at least once a month. Differences in costs and quality-adjusted life years (QALYs) based on the health-related quality-of-life instruments EQ-5D and EQ-VAS, and also the incremental cost-effectiveness ratio were investigated. All analyses used the intention-to-treat principle.

RESULTS

There were no significant differences between the intervention group and control group for total cost, EQ-5D-based QALY or EQ-VAS-based QALY for the 1-year study. Incremental cost-effectiveness ratio was not conducted because no significant differences were found for either EQ-5D- or EQ-VAS-based QALY, or costs. However, the intervention group had significantly lower levels of informal care and help with instrumental activities of daily living both as costs (<euro>3,927 vs. <euro>6,550, p = 0.037) and provided hours (200 vs. 333 hours per year, p = 0.037).

CONCLUSIONS

The intervention was cost neutral and does not seem to have affected health-related quality of life for the 1-year study, which may be because the follow-up period was too short. The intervention seems to have reduced hours and cost of informal care and help required with instrumental activities of daily living. This suggests that the intervention provides relief to informal caregivers.

Negative effects of diabetes-related distress on health-related quality of life: an evaluation among the adult patients with type 2 diabetes mellitus in three primary healthcare clinics in Malaysia

BACKGROUND

Patients with type 2 diabetes mellitus (T2D) often experienced change in life, altered self-esteem and increased feelings of uncertainty about the future that challenge their present existence and their perception of quality of life (QoL). There was a dearth of data on the association between diabetes-related distress (DRD) and health-related quality of life (HRQoL). This study examined the determinants of HRQoL, in particular the association between DRD and HRQoL by taking into account the socio-demographic-clinical variables, including depressive symptoms (DS) in adult patients with T2D.

METHODS

This cross-sectional study was conducted in 2012-2013 in three public health clinics in Malaysia. The World Health Organization Quality of Life-Brief (WHOQOL-BREF), 17-items Diabetes Distress Scale (DDS-17), and 9-items Patient Health Questionnaire (PHQ-9) were used to measure HRQoL, DRD and DS, respectively. The aim of this research was to examine the association between the socio-demographic-clinical variables and HRQoL as well as each of the WHOQOL-BREF domain score using multivariable regression analyses.

RESULTS

The response rate was 93.1% (700/752). The mean (SD) for age was 56.9 (10.18). The majority of the patients were female (52.8%), Malay (53.1%) and married (79.1%). About 60% of the patients had good overall HRQoL. The mean (SD) for Overall QoL, Physical QoL, Psychological QoL, Social Relationship QoL and Environmental QoL were 61.7 (9.86), 56.7 (10.64), 57.9 (11.73), 66.8 (15.01) and 65.3 (13.02), respectively. The mean (SD) for the total DDS-17 score was 37.1 (15.98), with 19.6% (136/694) had moderate distress. DDS-17 had a negative association with HRQoL but religiosity had a positive influence on HRQoL (B ranged between 3.07 and 4.76). Women, especially younger Malays, who had diabetes for a shorter period of time experienced better HRQoL. However, patients who were not married, had dyslipidaemia, higher levels of total cholesterol and higher PHQ-9 scores had lower HRQoL. Macrovascular complications showed the largest negative effect on the overall HRQoL (adjusted B = -4.98, 95% CI -8.56 to -1.40).

CONCLUSION

The majority of primary care adult with T2D had good overall HRQoL. Furthermore, the independent determinants for HRQoL had also concurred with many past studies. In addition, the researchers found that DRD had negative effects on HRQoL, but religiosity had positive influence on HRQoL. Appropriate support such as primary care is needed for adult patients with T2D to improve their life and their HRQoL.

TRIAL REGISTRATION

NMRR-12-1167-14158.

Older adults with chronic lung disease report less limitation compared with younger adults with similar lung function impairment

RATIONALE

Disability guidelines are often based on pulmonary function testing, but factors other than lung function influence how an individual experiences physiologic impairment. Age may impact the perception of impairment in adults with chronic lung disease.

OBJECTIVES

To determine if self-report of physical functional impairment differs between older adults with chronic lung disease compared with younger adults with similar degrees of lung function impairment.

METHODS

The Lung Tissue Research Consortium provided data on 981 participants with chronic obstructive pulmonary disease and interstitial lung disease who were well characterized with clinical, radiological, and pathological diagnoses. We used multiple logistic regression to determine if responses to health status questions (from the Short Form-12 and St. George's Respiratory Questionnaire) related to perception of impairment differed in older adults (age ≥ 65 yr, n = 427) compared with younger adults (age < 65 yr, n = 393).

MEASUREMENTS AND MAIN RESULTS

Pulmonary function was higher in older adults (median FEV1 %, 70) compared with younger adults (median FEV1 %, 62) (P < 0.001), whereas the median 6-minute-walk distance was similar between groups (372 m vs. 388 m, P = 0.21). After adjusting for potential confounders, older adults were less likely to report that their health limited them significantly in performing moderate activities (odds ratio [OR], 0.36; 95% confidence interval [CI], 0.22-0.58) or climbing several flights of stairs (OR, 0.51; 95% CI, 0.34-0.77). The odds of reporting that their physical health limited the kinds of activities they performed were reduced by 63% in older adults (OR, 0.37; 95% CI, 0.24-0.58), and, similarly, the odds of reporting that their health caused them to accomplish less than they would like were also lower in older adults (OR, 0.39; 95% CI, 0.25-0.60). The OR for reporting that their breathing problem stops them from doing most things or everything was 0.35 (95% CI, 0.22-0.55) in older adults versus younger adults.

CONCLUSIONS

Older adults with chronic lung disease were less likely to report significant impairment in their activities compared with younger adults, suggesting they may perceive less limitation.

A systematic review of instruments for measuring outcomes in economic evaluation within aged care

BACKGROUND

This paper describes the methods and results of a systematic review to identify instruments used to measure quality of life outcomes in older people. The primary focus of the review was to identify instruments suitable for application with older people within economic evaluations conducted in the aged care sector.

METHODS

Online databases searched were PubMed, Medline, Scopus, and Web of Science, PsycInfo, CINAHL, Embase and Informit. Studies that met the following criteria were included: 1) study population exclusively above 65 years of age 2) measured health status, health related quality of life or quality of life outcomes more broadly through use of an instrument developed for this purpose, 3) used a generic preference based instrument or an older person specific preference based or non-preference based instrument or both, and 4) published in journals in the English language after 2000.

RESULTS

The most commonly applied generic preference based instrument in both the community and residential aged care context was the EuroQol - 5 Dimensions (EQ-5D), followed by the Adult Social Care Outcomes Toolkit (ASCOT) and the Health Utilities Index (HUI2/3). The most widely applied older person specific instrument was the ICEpop CAPability measure for Older people (ICECAP-O) in both community and residential aged care.

CONCLUSION

In the absence of an ideal instrument for incorporating into economic evaluations in the aged care sector, this review recommends the use of a generic preference based measure of health related quality of life such as the EQ-5D to obtain quality adjusted life years, in combination with an instrument that has a broader quality of life focus like the ASCOT, which was designed specifically for evaluating interventions in social care or the ICECAP-O, a capability measure for older people.

Health and Quality of Life Perception in Older Adults: The Joint Role of Cognitive Efficiency and Functional Mobility

Cognitive and mobility functions are involved in health-related quality of life (HRQoL). The present cross-sectional study aimed at investigating what facets of efficient cognition and functional mobility interactively contribute to mental and physical HRQoL. Fifty-six healthy older individuals (aged 65–75 years) were evaluated for mental and physical HRQoL, core cognitive executive functions (inhibition, working memory, and cognitive flexibility), and functional mobility (walking) under single and dual task conditions. Multiple regression analyses were run to verify which core executive functions predicted mental and physical HRQoL and whether the ability to perform complex (dual) walking tasks moderated such association. Inhibitory efficiency and the ability to perform physical-mental dual tasks interactively predicted mental HRQoL, whereas cognitive flexibility and the ability to perform physical dual tasks interactively predicted physical HRQoL. Different core executive functions seem relevant for mental and physical HRQoL. Executive function efficiency seems to translate into HRQoL perception when coupled with tangible experience of the ability to walk under dual task conditions that mirror everyday life demands. Implications of these results for supporting the perception of mental and physical quality of life at advanced age are discussed, suggesting the usefulness of multicomponent interventions and environments conducive to walking that jointly aid successful cognitive aging and functional mobility.

A prospective, longitudinal, observational cohort study examining how glaucoma affects quality of life and visually-related function over 4 years: design and methodology

Background

The aim of this study is to summarize the design and methodology of a prospective, longitudinal, observational cohort study to investigate how glaucoma affects patients’ quality of life and visually-related function over a 4-year period.

Methods/Design

One hundred sixty-one (161) subjects were enrolled in this ongoing study. Patients between the ages of 21–85 years with a minimum 2-year diagnosis of primary open-angle glaucoma, chronic primary angle-closure glaucoma or pseudoexfoliation glaucoma were included. Each patient visited Wills Eye Hospital for a baseline visit. Follow-up is planned for a minimum of 4 years, with annual visits. Each visit includes (1) Clinical evaluation: a slit lamp examination, fundoscopy, intraocular pressure measurement, visual field examination, spectral domain optical coherence tomography, Pelli-Robson Contrast Sensitivity test and the Spaeth-Richman Contrast Sensitivity test; (2) a performance based measure: the Compressed Assessment of Ability Related to Vision; and (3) Subjective measures of vision-related quality of life (the National Eye Institute Visual Functioning Questionnaire 25 and the Modified Glaucoma Symptom Scale).

Discussion

The results of this ongoing, prospective, longitudinal study are expected to shed light on the relationships between clinical measures, performance-based measures and subjective measures of well-being, in order to assess changes in the quality of life and the ability to function of patients with glaucoma over time.

Significant predictors of poor quality of life in older asthmatics

BACKGROUND

Morbidity and mortality from asthma are high in older adults and quality of life (QOL) might be lower, although standardized measurements of QOL have not been validated in this population.

OBJECTIVE

To determine predictors of asthma-related QOL in older adults.

METHODS

Allergy and pulmonary outpatients (n = 164) at least 65 years old with an objective diagnosis of asthma completed the Mini-Asthma Quality of Life Questionnaire (mAQLQ). Demographics, medical history, and mean value for daily elemental carbon attributable to traffic, a surrogate for diesel exposure, were obtained. Regression analysis was used to determine predictors of mAQLQ scores.

RESULTS

Total mAQLQ (mean ± SD 5.4 ± 1.1) and symptom, emotional, and activity domain scores were similar to those of younger populations, whereas environmental domain scores (4.4 ± 1.7) appeared lower. Poorer mAQLQ scores were significantly associated with emergency department visits (adjusted β [aβ] = -1.3, where β values indicate the strength and direction of association, P < .0001) and with poorer scores on the Asthma Control Questionnaire (aβ = -0.7, P < .0001). Greater ECAT exposure (aβ = -1.6, P < .02), female sex (aβ = -0.4, P < .006), body mass index of at least 30 kg/m(2) (aβ = -0.4, P < .01), gastroesophageal reflux (aβ = -0.4, P < .01), nonatopic status (aβ = -0.5, P < .002), and asthma onset before 40 years of age (aβ = -0.5, P < .004) were significantly associated with poorer mAQLQ scores.

CONCLUSION

The mAQLQ scores in older adults with stable asthma were similar to those in younger populations and were predictive of other measurements of asthma control, verifying that the mAQLQ is an appropriate tool in older adults with asthma. Traffic pollution exposure was the strongest predictor of poorer asthma-related QOL in older adults with asthma.

Obesity in the Context of Aging: Quality of Life Considerations

The progressive increase in the prevalence of obesity and aging in the population is resulting in increased healthcare and disability spending. The burden of obesity is particularly relevant in old age, due to accumulating co-morbidities and changes in body composition. Sarcopenic obesity, a mix of over- and under-nutrition, causes frailty, disability, and problems in social and psychological areas, impacting overall health-related quality of life (HR-QOL). The relationship between obesity, aging, and HR-QOL is, however, much more complex than generally acknowledged and is difficult to disentangle. The impact of obesity on HR-QOL is particularly strong in young people, who are free of co-morbidities. It progressively attenuates, compared with the general population, with advancing age, when co-morbid conditions are diffusely present and reduce the perceived health status, independent of obesity. However, even this apparent 'obesity paradox' should not minimize the importance of obesity on HR-QOL, as other obesity-associated limitations and disabilities do impact HR-QOL in older age. A patient-centered approach aimed at reducing the disability and social isolation of advancing age is mandatory to improve HR-QOL in any class of obesity.

The "Wound-QoL": a short questionnaire measuring quality of life in patients with chronic wounds based on three established disease-specific instruments

The aim of this study was to develop a short questionnaire measuring health-related quality of life (HRQoL) in chronic wounds. Three validated instruments assessing HRQoL in chronic wounds-the Freiburg Life Quality Assessment for wounds, the Cardiff Wound Impact Schedule, and the Würzburg Wound Score-were completed by 154 German leg ulcer patients in a longitudinal study. For implementation in the new, shorter questionnaire Wound-QoL, all of those 92 items that covered the core content of the three questionnaires and showed good psychometric properties were selected. Internal consistency, convergent validity, and responsiveness were analyzed using the study data on the selected items (a new approach called virtual validation). Subscales were determined with factor analysis. Item, instruction, and response scale wording were harmonized. Seventeen items were included in the Wound-QoL, which could be attributed to three subscales on everyday life, body, and psyche. Both global score and subscale scores were internally consistent with Cronbach's alpha between 0.71 and 0.91. The global score showed significant convergent validity (r = 0.48 to 0.69) and responsiveness (r = 0.18 to 0.52); the same was true for the subscale scores. The Wound-QoL for measurement of HRQoL in chronic wounds proved to be internally consistent, valid, and responsive in German leg ulcer patients. The findings of this virtual validation study need to be confirmed in a longitudinal validation study on the final Wound-QoL, which is currently being conducted.

Factors that influence physical function and emotional well-being among Medicare-Medicaid enrollees

Dually enrolled Medicare-Medicaid older adults are a vulnerable population. We tested House's Conceptual Framework for Understanding Social Inequalities in Health and Aging in Medicare-Medicaid enrollees by examining the extent to which disparities indicators, which included race, age, gender, neighborhood poverty, education, income, exercise (e.g., walking), and physical activity (e.g., housework) influence physical function and emotional well-being. This secondary analysis included 337 Black (31%) and White (69%) older Medicare-Medicaid enrollees. Using path analysis, we determined that race, neighborhood poverty, education, and income did not influence physical function or emotional well-being. However, physical activity (e.g., housework) was associated with an increased self-report of physical function and emotional well-being of β = .23, p < .001; β = .17, p < .01, respectively. Future studies of factors that influence physical function and emotional well-being in this population should take into account health status indicators such as allostatic load, comorbidity, and perceived racism/discrimination.

Systematic review of health-related quality of life measures for inflammatory bowel disease

BACKGROUND AND AIM

Several measures have been developed to assess the health-related quality of life [HRQoL] of patients with inflammatory bowel disease [IBD]. Our aim is to systematically review the HRQoL measures specific for patients with IBD and to appraise their measurement properties and methodological quality.

METHODS

We searched the PubMed, Embase, and PsycINFO databases for original articles describing the development and/or evaluation of one or more of the measurement properties [e.g. internal consistency, reliability, validity, responsiveness] of HRQoL measures specific for IBD. We assessed the measurement properties and examined the methodological quality of the measurement properties of each instrument using a standardized checklist.

RESULTS

We examined the full text of 75 articles that we deemed potentially eligible and identified 10 disease-specific HRQoL measures in IBD that covered different aspects of patients' lives. Internal consistency, construct validity, and content validity were the commonly evaluated measurement properties. Seven HRQoL measures scored positive for at least four of eight measurement properties. The majority of studies were rated as 'fair' to 'poor' when assessing their methodology quality. The most established HRQoL measure in the literature was the Inflammatory Bowel Disease Questionnaire [IBDQ].

CONCLUSIONS

Most of the included HRQoL measures did not include all the required measurement properties or had a problem with their methodological quality. The most widely used and validated measure was the IBDQ. Further validation studies are required to support the use of other HRQoL measures.

Health status and quality of life: results from a national survey in a community-dwelling sample of elderly people

PURPOSE

To investigate the relation between age and HRQoL indicators in a community-dwelling population aged 65 years and older.

METHODS

Data were collected within a sample stratified by age (65-69; 70-74; 75-79; 80-84; 85-89; 90 years and above) and sex and randomly selected in the population records in Switzerland. The EQ-5D was used to assess HRQoL. Analyses were conducted on the entire available sample (N = 3,073) and on the subsample with no missing data in the EQ-5D (N = 2,888), considering age, gender, education and region.

RESULTS

Results of multiple regression analyses showed different age-related patterns across the EQ-5D. The proportion of respondents reporting no problems ranged from 51 % in the 65- to 69-year age group to 20 % in the 90 years and above age group. Odds ratio (OR) for Mobility problems increased from 2.04 in the 75- to 79-year age group to 13.34 in the 90 years and above age group; OR for Usual Activities increased from 1.76 to 11.68 and from 1.55 to 2.32 for Pain/Discomfort; OR for Self-Care increased from 5.26 in the 80- to 84-year age group to 30.36 in the 90 years and above age group. Problems with Self-Care remained low, increasing from 6.22 % in the 80- to 84-year age group to 26.21 % in the oldest age group. The magnitude of the gender, region and education effects was much lower than that of age.

CONCLUSION

HRQoL is globally preserved in older adults in Switzerland, even if substantial impairment is reported in very old age affecting mainly functional health dimensions. Anxiety/Depression and Pain/Discomfort did not appear to be affected by age; high rates of difficulties were reported for Pain/Discomfort but not for Anxiety/Depression.

Impact of locomotion training with a neurologic controlled hybrid assistive limb (HAL) exoskeleton on neuropathic pain and health related quality of life (HRQoL) in chronic SCI: a case study (.)

Chronic neuropathic pain (CNP) is a common condition associated with spinal cord injury (SCI) and has been reported to be severe, disabling and often treatment-resistant and therefore remains a clinical challenge for the attending physicians. The treatment usually includes pharmacological and/or nonpharmacological approaches. Body weight supported treadmill training (BWSTT) and locomotion training with driven gait orthosis (DGO) have evolved over the last decades and are now considered to be an established part in the rehabilitation of SCI patients. Conventional locomotion training goes along with improvements of the patients' walking abilities in particular speed and gait pattern. The neurologic controlled hybrid assistive limb (HAL®, Cyberdyne Inc., Ibraki, Japan) exoskeleton, however, is a new tailored approach to support motor functions synchronously to the patient's voluntary drive. This report presents two cases of severe chronic and therapy resistant neuropathic pain due to chronic SCI and demonstrates the beneficial effects of neurologic controlled exoskeletal intervention on pain severity and health-related quality of life (HRQoL). Both of these patients were engaged in a 12 weeks period of daily HAL®-supported locomotion training. In addition to improvements in motor functions and walking abilities, both show significant reduction in pain severity and improvements in all HRQoL domains. Although various causal factors likely contribute to abatement of CNP, the reported results occurred due to a new approach in the rehabilitation of chronic spinal cord injury patients. These findings suggest not only the feasibility of this new approach but in conclusion, demonstrate the effectiveness of neurologic controlled locomotion training in the long-term management of refractory neuropathic pain. Implications for Rehabilitation CNP remains a challenge in the rehabilitation of chronic SCI patients. Locomotion training with the HAL exoskeleton seems to improve CNP in chronic SCI. HAL locomotion training is feasible and safe in the rehabilitation of chronic SCI patients.

Emotional intelligence and health-related quality of life in institutionalised Spanish older adults

This study explores the relationship between emotional intelligence (EI) and health-related quality of life (HRQoL) in a sample of Spanish older adults who are institutionalised in long-term care (LTC) facilities. One hundred fifteen institutionalised individuals (47.82% women; 88.3 ± 7.9 years) from southern Spain completed a set of questionnaires that included measures of EI, health and personality. Data were analysed via hierarchical regression. After controlling for personality and sociodemographic variables, the EI dimensions, emotional comprehension and emotional facilitation, accounted for part of the variance in several HRQoL facets. These dimensions could have an important role in the HRQoL of residents in LTC. Moreover, the use of a performance measure addresses the limitations of previous studies that have relied on self-report measures. These aspects underscore the importance of the results of this study.

Relationship between falls, knee osteoarthritis, and health-related quality of life: data from the Osteoarthritis Initiative study

BACKGROUND

The purpose of this study was to examine the relationship between self-reported falls, doctor-diagnosed knee osteoarthritis (OA), and health-related quality of life (HRQoL). We hypothesized that falls and knee OA would be associated with poor HRQoL on both disease-specific and generic measures.

METHODS

This cross-sectional study used data from the publicly available Osteoarthritis Initiative data sets. A total of 4,484 subjects aged 45-79 years at baseline were divided into three subpopulations: those who had neither a history of falling nor doctor-diagnosed knee OA; those who had either a self-reported history of falling or doctor-diagnosed knee OA; and those who had both a self-reported history of falling and doctor-diagnosed knee OA. HRQoL was assessed using both disease-specific and generic measures. Multiple regression analyses were used to examine the relationship between self-reported falls, doctor-diagnosed knee OA, and HRQoL assessed using the Knee Injury and Osteoarthritis Outcome Score-Quality of Life (KOOS-QoL) subscale and two Short Form-12 (SF-12) summary scales. The models were adjusted for participant sociodemographic, lifestyle, and clinical characteristics.

RESULTS

Falls and knee OA were significantly associated with lower scores on the KOOS-QoL (β= -34.4, standard error 2.27, P≤0.0001) and on the physical component scale of the SF-12 (β= -9.44, standard error 0.90, P<0.0001). No significant relationship was found with the mental component scale score when adjusted for sociodemographic, lifestyle, and clinical characteristics.

CONCLUSION

When compared with those having neither a self-reported history of falling nor doctor-diagnosed knee OA and those with a self-reported history of falling or doctor-diagnosed knee OA, persons with both conditions (falls and knee OA) had significantly lower KOOS-QoL and physical component scale scores after adjusting for sociodemographic, lifestyle, and clinical characteristics. Future research should assess potential mediating factors in an effort to improve HRQoL in persons with knee OA who are at high risk of falling.

Sense of coherence and quality of life in older in-hospital patients without cognitive impairment--a 12 month follow-up study

BACKGROUND

The relation between sense of coherence (SOC) and quality of life (QoL) among older persons has been found in some, but not all, studies and mostly in studies with cross-sectional design. We wanted to study if SOC was associated with domains of QoL at hospitalization and one year later among persons 65 years and above without cognitive impairment.

METHOD

At hospitalization (T1) and 12 month follow-up (T2) QoL and cognitive status were assessed using the WHOQOL-BREF and the Mini-Mental State Examination. At baseline, the 13-item version of the SOC scale was used to assess coping, the Hospital Anxiety and Depression Scale (HADS) was used to assess depressive and anxiety symptoms. Level of functioning was rated using Lawton and Brody's scales for physical self-maintenance and instrumental activities of daily living (personal and instrumental ADL).

RESULTS

In total, 165 (80 men) persons with a mean age of 77.7 (SD 6.9) years were included. The proportion of people rating their overall QoL as high had decreased from T1 to T2. The mean score on QoL- physical domain had increased, while the mean score of QoL-environmental domain had decreased. In adjusted regression analyses at T1, a high level of SOC was positively associated with QoL in three of four domains, i.e. physical, psychological and environmental, but level of SOC assessed at T1 was not associated with any domain of QoL at T2. Personal ADL was associated with some domains of QOL at T1 and T2.

CONCLUSION

The SOC level was associated with older adult's QoL during hospitalization but not their QoL one year after the hospital stay.

B vitamin and/or n-3 fatty acid supplementation and health-related quality of life: ancillary findings from the SU.FOL.OM3 randomized trial

Background

Despite growing attention to nutrition and quality of life in cardiovascular disease survivors, the impact of dietary factors according to disease type or to quality of life domain is poorly understood. We investigated the effects of B vitamin and/or n-3 fatty acid supplementation on health-related quality of life among survivors of stroke, myocardial infarction, or unstable angina.

Methods

We performed ancillary analyses of the SU.FOL.OM3 trial (2003–2009; France). In total, 2,501 men (mean age = 61 y) and women (mean age = 63 y) were randomized in a 2×2 factorial design to: 1) 0.56 mg 5-methyl-tetrahydrofolate, 3 mg vitamin B6, 0.02 mg vitamin B12; 2) 600 mg eicosapentaenoic and docosahexaenoic acids in a 2∶1 ratio; 3) B vitamins and n-3 fatty acids combined; or 4) placebo. Health-related quality of life was evaluated at follow-up with the Medical Outcomes Study 36-Item Short Form Health Survey. Data from 2,029 individuals were used in this analysis.

Results

After 3.1±0.4 y, no effects of supplementation with either B vitamins or n-3 fatty acids on quality of life (physical or mental health domains) were found. However, participants receiving B vitamins had slightly more activity limitations due to emotional problems compared with those not receiving B vitamins (mean difference = 3.8; 95% CI: 0.4, 7.1). A significant interaction of treatment by prior disease revealed an inverse association between n-3 fatty acids and vitality among myocardial infarction survivors (mean difference = 2.9; 95% CI: 0.5, 5.2).

Conclusions

There were no beneficial effects of supplementation with relatively low doses of B vitamins or n-3 fatty acids on health-related quality of life in cardiovascular disease survivors. The adverse effects of B vitamins on activity limitations and of n-3 fatty acids on vitality among individuals with prior myocardial infarction merit confirmation.

Nutritional status in chronically-ill elderly patients. Is it related to quality of life?

OBJECTIVE

The aim of this study is to assess the quality of life in chronically-ill elderly patients and its relationship with parameters concerning the patients' nutritional status.

DESIGN

A cross-sectional study.

SETTING

Primary health-care centres in Jaen, Spain.

PARTICIPANTS

A total of 168 chronically-ill elderly outpatients aged from 65 to 89 years.

MEASUREMENTS

Quality of life was measured using the World Health Organization Quality of Life (WHOQOL-BREF) questionnaire. A nutritional assessment was undertaken including socio-demographic variables, anthropometric measurements (body-mass index and calf circumference), functional evaluation (Barthel index and Folstein mini-mental status test) and a dietetic questionnaire. The mini-nutritional assessment test was used as an assessment tool to detect nutritional risk.

RESULTS

Quality of life in chronically-ill elderly subjects, as determined by the WHOQOL-BREF questionnaire, which diminishes with age, is independent of anthropometric parameters and a statistically significant difference was found between gender, socio-demographic characteristics, functional capacity, nutritional status and the kind of chronic disease (p<0.05).

CONCLUSION

The relationship between the quality of life with the patients' socio-demographic characteristics, functional capacity and nutritional status underlines the importance of taking these factors into account in the management of chronically ill patients, especially women.

Cognitive Trajectory After Transcatheter Aortic Valve Implantation

Background—

Transcatheter aortic valve implantation (TAVI) is known to be associated with silent cerebral injury, which could contribute to cognitive impairment. Considering its increasing use, thorough longitudinal investigation of cognitive trajectory after TAVI is pivotal.

Methods and Results—

Repeatable battery for the assessment of neuropsychological status was performed before (E1), 3 days (E2), 3 months (E3), 1 (E4) year, and 2 years (E5) after TAVI. Baseline characteristics, procedural data, imaging parameters of brain injury (diffusion-weighted MRI), and the use of conceivable neuroprotective approaches were investigated for their effect on cognitive function. Cognitive performance was investigated in 111 patients (mean log EuroSCORE, 30±13%). Global cognitive function (repeatable battery for the assessment of neuropsychological status total score) increased transiently at E2 ( P =0.02) and was comparable with baseline levels at E3, E4, and E5. Six patients (5.4%) demonstrated early cognitive decline. Persistence and late onset were seen infrequently (n=3, 2.7% and n=4, 3.6%, respectively). Hence, early cognitive decline was ruled out in 105 patients (94.6%), and a majority of patients (91%) demonstrated sustained cognitive performance throughout all investigated time points. Interestingly, only patient age ( P =0.012), but not prior cerebrovascular events, cognitive status, direct TAVI, cerebral embolism in diffusion-weighted MRI, or the use of a cerebral embolic protection device was found to be independently associated with cognitive decline, linking higher age to cognitive impairment along the first 2 years after TAVI.

Conclusions—

Long-term cognitive performance was preserved in the great majority (91%) of patients throughout the first 2 years after TAVI, despite the high intrinsic risk for cognitive deterioration.

Clinical Trial Registration—

URL: http://www.clinicaltrials.gov . Unique identifier: NCT00883285.

Multimorbidity's research challenges and priorities from a clinical perspective: the case of 'Mr Curran'

Older patients, suffering from numerous diseases and taking multiple medications are the rule rather than the exception in primary care. A manifold of medical conditions are often associated with poor outcomes, and their multiple medications raise additional risks of polypharmacy. Such patients account for most healthcare expenditures. Effective approaches are needed to manage such complex patients in primary care. This paper describes the results of a scoping exercise, including a two-day workshop with 17 professionals from six countries, experienced in general practice and primary care research as well as epidemiology, clinical pharmacology, gerontology and methodology. This was followed by a consensus process investigating the challenges and core questions for multimorbidity research in primary care from a clinical perspective and presents examples of the best research practice. Current approaches in measuring and clustering multimorbidity inform policy-makers and researchers, but research is needed to provide support in clinical decision making. Multimorbidity presents a complexity of conditions leading to individual patient's needs and demanding complex processes in clinical decision making. The identification of patterns presupposes the development of strategies on how to manage multimorbidity and polypharmacy. Interventions have to be complex and multifaceted, and their evaluation poses numerous methodological challenges in study design, outcome measurement and analysis. Overall, it can be seen that complexity is a main underlying theme. Moreover, flexible study designs, outcome parameters and evaluation strategies are needed to account for this complexity.

Prognostic value of cerebral injury following transfemoral aortic valve implantation

AIMS

To evaluate the impact of serological, imaging and clinical measures of cerebral injury on patient self-sufficiency and survival after transcatheter aortic valve implantation (TAVI).

METHODS AND RESULTS

Before and three days after TAVI, neuron-specific enolase (NSE), cerebral diffusion-weighted magnetic resonance imaging (DW-MRI) and neurological performance utilising National Institutes of Health Stroke Scale (NIHSS) were assessed. Self-sufficiency was determined with established score systems (instrumental activities of daily living score, Barthel Index). Parameters of cerebral injury were investigated for their impact on self-sufficiency and all-cause mortality after 30 days and one year. Sixty-one patients were enrolled (logistic EuroSCORE: 26.4±18.1, STS score: 7.9±5.7), of whom 39 completed the imaging protocol. The incidences of NSE increase, new embolic events in DW-MRI, and neurological deficit early after TAVI were 52.4%, 71.8% and 6.6%, respectively. The degree of concomitant comorbidities, reflected by higher risk scores, had significant impact on outcome. Plasma levels of NSE and new emboli in DW-MRI were neither related to self-sufficiency nor to survival one year after TAVI.

CONCLUSIONS

In this observational pilot study, "silent" cerebral injury is neither related to dependent lifestyle nor to mortality during the first year after TAVI. However, long-term follow-up is needed to elucidate fully the impact of silent stroke. Clinical trials number: NCT00883285.

Health-related quality of life in gout: a systematic review

Objectives. To identify the instruments that have been used to measure health-related quality of life (HRQOL) in gout and assess their clinimetric properties, determine the distribution of HRQOL in gout and identify factors associated with poor HRQOL.

Methods. Medline, CINAHL, EMBASE and PsycINFO were searched from inception to October 2012. Search terms pertained to gout, health or functional status, clinimetric properties and HRQOL. Study data extraction and quality assessment were performed by two independent reviewers.

Results. From 474 identified studies, 22 met the inclusion criteria. Health Assessment Questionnaire Disability Index (HAQ-DI) and Short Form 36 (SF-36) were most frequently used and highest rated due to robust construct and concurrent validity, despite high floor and ceiling effects. The Gout Impact Scale had good content validity. Gout had a greater impact on physical HRQOL compared to other domains. Both gout-specific features (attack frequency and intensity, intercritical pain and number of joints involved) and comorbid disease were associated with poor HRQOL. Evidence for objective features such as tophi and serum uric acid was less robust. Limitations of existing studies include cross-sectional design, recruitment from specialist clinic settings and frequent use of generic instruments.

Conclusion. Most studies have used the generic HAQ-DI and SF-36. Gout-specific characteristics and comorbidities contribute to poor HRQOL. There is a need for a cohort study in primary care (where most patients with gout are treated) to determine which factors predict changes in HRQOL over time. This will enable those at risk of deterioration to be identified and better targeted for treatment.

Quality of life in sarcopenia and frailty

The reduced muscle mass and impaired muscle performance that define sarcopenia in older individuals are associated with increased risk of physical limitation and a variety of chronic diseases. They may also contribute to clinical frailty. A gradual erosion of quality of life (QoL) has been evidenced in these individuals, although much of this research has been done using generic QoL instruments, particularly the SF-36, which may not be ideal in older populations with significant comorbidities. This review and report of an expert meeting presents the current definitions of these geriatric syndromes (sarcopenia and frailty). It then briefly summarizes QoL concepts and specificities in older populations and examines the relevant domains of QoL and what is known concerning QoL decline with these conditions. It calls for a clearer definition of the construct of disability, argues that a disease-specific QoL instrument for sarcopenia/frailty would be an asset for future research, and discusses whether there are available and validated components that could be used to this end and whether the psychometric properties of these instruments are sufficiently tested. It calls also for an approach using utility weighting to provide some cost estimates and suggests that a time trade-off study could be appropriate.

Quality of life in China rural-to-urban female migrant factory workers: a before-and-after study

Background

Rural-to-urban female migrant workers have a lower quality of life compared to the general population. Improving these conditions remains highly challenging. This paper reports the health-related quality of life (HRQoL) of the female migrant workers in an educational project.

Methods

In this before-and-after study, a community-based health education intervention was developed to improve female migrant workers’ HRQoL and job satisfaction. A factory was selected as the location to implement the trial, using a before-and-after design. The education intervention included distribution and free access to study materials, monthly lectures, and counseling. The primary endpoint was HRQoL, and gynecological disease and job satisfaction were secondary endpoints. We assessed HRQoL at baseline and at 6-month follow-up using the Health Survey Short Form (SF-36).

Results

Compared to the baseline assessment, the participants at the 6-month survey reported higher General Health scores (standardized-β coefficients (Betas) of β = 0.056; P <0.001), Vitality scores (β = 0.066; P <0.001), Mental Health scores (β = 0.062; P <0.001), mental component summary scores (β = 0.040; P <0.001), and job satisfaction (Odds Ratio [OR] 2.104, 95% confidence interval [CI] 1.837-2.408; P <0.01).

Conclusions

A community-based educational intervention, targeted at female migrant workers, appears effective in improving HRQoL and job satisfaction.

Revisiting quality of life for elders in long-term care: an integrative review

PURPOSE

To review the literature on quality of life (QOL) among elders in long-term care settings, specifically focusing on measurement of QOL, influencing factors, and interventions to improve QOL.

CONCLUSION

Multiple instruments were used to measure QOL with little overlap and limited ability to compare across studies. Categories of influencing factors included physical function, environment, social support, and mood/spiritual. Interventions targeted changes in environment, physical activity, and meaningful interaction.

PRACTICE IMPLICATION

Knowledge of the factors influencing QOL and findings from research on interventions will assist nurses in individualizing care approaches to improve QOL among elders in long-term care settings.