Methods for Assessing Quality of Life and Well-Being in Frail Older People

The association between loneliness, social isolation and all-cause mortality in a nationally representative sample of older women and men

OBJECTIVES

Individuals who feel lonely and those who are socially isolated have higher mortality risks than those who are not lonely or socially isolated. However, the importance of loneliness and social isolation for survival is rarely analysed in the same study or with consideration of gender differences. The aim was to examine the separate, mutually adjusted, and combined effects of loneliness and social isolation with mortality in older women and men.

METHODS

Data from the SWEOLD study, a nationally representative sample of people aged 69+ years living in Sweden, was combined with register data on mortality and analysed using Cox regressions.

RESULTS

Mortality was higher among older women and men with higher levels of loneliness or social isolation. Social isolation was more strongly associated with mortality than loneliness and the association remained when controlling for health. The combined effects of loneliness and social isolation did not surpass their independent effects.

CONCLUSION

Loneliness and social isolation is associated with an increased mortality risk, and social integration should be a prioritised target for activities and services involving older adults.

Care home residents’ quality of life and its association with CQC ratings and workforce issues: the MiCareHQ mixed-methods study

Background

Care home staff have a critical bearing on quality. The staff employed, the training they receive and how well they identify and manage residents’ needs are likely to influence outcomes. The Care Act 2014 (Great Britain. The Care Act 2014. London: The Stationery Office; 2014) requires services to improve ‘well-being’, but many residents cannot self-report and are at risk of exclusion from giving their views. The Adult Social Care Outcomes Toolkit enables social care-related quality of life to be measured using a mixed-methods approach. There is currently no equivalent way of measuring aspects of residents’ health-related quality of life. We developed new tools for measuring pain, anxiety and depression using a mixed-methods approach. We also explored the relationship between care home quality, residents’ outcomes, and the skill mix and employment conditions of the workforce who support them.

Objectives

The objectives were to develop and test measures of pain, anxiety and depression for residents unable to self-report; to assess the extent to which regulator quality ratings reflect residents’ care-related quality of life; and to assess the relationship between aspects of the staffing of care homes and the quality of care homes.

Design

This was a mixed-methods study.

Setting

The setting was care homes for older adults in England.

Participants

Care home residents participated.

Results

Three measures of pain, anxiety and low mood were developed and tested, using a mixed-methods approach, with 182 care home residents in 20 care homes (nursing and residential). Psychometric testing found that the measures had good construct validity. The mixed-methods approach was both feasible and necessary with this population, as the majority of residents could not self-report. Using a combined data set (n = 475 residents in 54 homes) from this study and the Measuring Outcomes in Care Homes study (Towers AM, Palmer S, Smith N, Collins G, Allan S. A cross-sectional study exploring the relationship between regulator quality ratings and care home residents’ quality of life in England. Health Qual Life Outcomes 2019;17:22) we found a significant positive association between residents’ social care-related quality of life and regulator (i.e. Care Quality Commission) quality ratings. Multivariate regression revealed that homes rated ‘good/outstanding’ are associated with a 12% improvement in mean current social care-related quality of life among residents who have higher levels of dependency. Secondary data analysis of a large, national sample of care homes over time assessed the impact of staffing and employment conditions on Care Quality Commission quality ratings. Higher wages and a higher prevalence of training in both dementia and dignity-/person-centred care were positively associated with care quality, whereas high staff turnover and job vacancy rates had a significant negative association. A 10% increase in the average care worker wage increased the likelihood of a ‘good/outstanding’ rating by 7%.

Limitations

No care homes rated as inadequate were recruited to the study.

Conclusions

The most dependent residents gain the most from homes rated ‘good/outstanding’. However, measuring the needs and outcomes of these residents is challenging, as many cannot self-report. A mixed-methods approach can reduce methodological exclusion and an over-reliance on proxies. Improving working conditions and reducing staff turnover may be associated with better outcomes for residents.

Future work

Further work is required to explore the relationship between pain, anxiety and low mood and other indicators of care homes quality and to examine the relationship between wages, training and social care outcomes.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 19. See the NIHR Journals Library website for further project information.

Exploring the meaning of quality of life for assisted living residents: A photo-elicitation study

Assisted living is a popular alternative to residential care, promoting independence and enabling self-care through a supportive living environment. Practitioner understanding of quality of life (QoL) experiences are vital to facilitate good physical and mental health in assisted living. An idiographic case study approach explored resident experiences by combining photo-elicitation and interpretive phenomenological analysis. QoL was understood through three themes: facilitation of identity coherence and transition, the essential nature of socialising, and perceptions of a supportive environment. Assisted living has the potential to act as a bearer for cues of identity continuity with nostalgic devices facilitating environment transition and limiting biographical disruption. Furthermore, opportunities for social contact offer a protective function for residents adapting to negative life challenges such as bereavement. To foster health and QoL in withdrawn residents' facilities should develop peer support programmes with benefits for both mentor and mentee.

Trends and Inequality in the New Active Ageing and Well-Being Index of the Oldest Old: a Case Study of Sweden

The policy discourse on active ageing and well-being at the European level tends to have a strong focus on the experiences of the ‘young old’. In this study the focus instead is on the oldest old (75 years and older). The theoretical framework is inspired by the Active Ageing Index and the Nordic welfare research tradition. Active ageing and well-being indicators and domains of high relevance for the oldest old are used and a new Active Ageing-Well Being Index (AA-WB Index) is developed. Our aim is to go beyond averages and analyse changes over time and inequality in the AA-WB Index. The prime data is derived from two waves, 2004 and 2014, of the Swedish Panel Study of Living Conditions of the Oldest Old (SWEOLD), a nationally representative sample of older people. The results show an overall improvement in most domains of the AA-WB index, especially in the indicator participation in cultural and leisure activities. The findings also show clear and consistent gender and educational inequalities. In addition, the different domains correlate, implying that inequality within a domain is aggravated by the inequality in another domain. The study highlights that measurements on active ageing and well-being should place a greater importance on the living conditions of the oldest old with a special focus on inequality.

Development of an ICT-Based Dementia Care Mapping Support System and Its Usefulness Assessment

Objectives:

Dementia Care Mapping (DCM) is an established practice method to implement Person-centred Care in dementia care settings. However, it is not easy to carry out DCM because of its high complexity. The aim of this study is to solve DCM complexity by adopting technology.

Methods:

Authors developed (1) a new information-communication technology (ICT) based DCM support system based on the investigation of difficulties and/or burden encountered during mapping (n = 33) and (2) a new evaluation test method, using role-play videos, for assessing the usefulness and reliability of the system. Mapping data, collected using the support system or the conventional paper-based DCM (n = 22), were compared.

Results:

We obtained users’ positive ratings of the system for burden reduction and its usability. Moreover, the developed prototype system indicated to have already reached the level of conventional paper-based DCM in terms of mapping accuracy.

Conclusion:

Usefulness of the ICT-based support system was confirmed to help overcome DCM complexity.

Development and Examination of a Family Triadic Measure to Examine Quality of Life Family Congruence in Nursing Home Residents and Two Family Members

Objective: The overall purpose of this study was to propose and test a conceptual model and apply family analyses methods to understand quality of life family congruence in the nursing home setting. Method: Secondary data for this study were from a larger study, titled Measurement, Indicators and Improvement of the Quality of Life (QOL) in Nursing Homes. Research literature, family systems theory and human ecological assumptions, fostered the conceptual model empirically testing quality of life family congruence. Results: The study results supported a model examining nursing home residents and two family members on quality of life family congruence. Specifically, family intergenerational dynamic factors, resident personal and social-psychological factors, and nursing home family input factors were examined to identify differences in quality of life family congruence among triad families. Discussion: Formal family involvement and resident cognitive functioning were found as the two most influential factors to quality of life family congruence (QOLFC).

The physical environment, activity and interaction in residential care facilities for older people: a comparative case study

The physical environment is of particular importance for supporting activities and interactions among older people living in residential care facilities (RCFs) who spend most of their time inside the facility. More knowledge is needed regarding the complex relationships between older people and environmental aspects in long-term care. The present study aimed to explore how the physical environment influences resident activities and interactions at two RCFs by using a mixed-method approach. Environmental assessments were conducted via the Swedish version of the Sheffield Care Environment Assessment Matrix (S-SCEAM), and resident activities, interactions and locations were assessed through an adapted version of the Dementia Care Mapping (DCM). The Observed Emotion Rating Scale (OERS) was used to assess residents' affective states. Field notes and walk-along interviews were also used. Findings indicate that the design of the physical environment influenced the residents' activities and interactions. Private apartments and dining areas showed high environmental quality at both RCFs, whereas the overall layout had lower quality. Safety was highly supported. Despite high environmental quality in general, several factors restricted resident activities. To optimise care for older people, the design process must clearly focus on accessible environments that provide options for residents to use the facility independently.

The acceptability and feasibility of using the Adult Social Care Outcomes Toolkit (ASCOT) to inform practice in care homes

BACKGROUND

The Adult Social Care Outcomes Toolkit (ASCOT) measures social care related quality of life (SCRQoL) and can be used to measure outcomes and demonstrate impact across different social care settings. This exploratory study built on previous work by collecting new inter-rater reliability data on the mixed-methods version of the toolkit and exploring how it might be used to inform practice in four case study homes.

METHOD

We worked with two care home providers to agree an in-depth study collecting SCRQoL data in four case-study homes. Data was collected about residents' age, ethnicity, cognitive impairment, ability to perform activities of daily living and SCRQoL in the four homes. Feedback sessions with staff and managers were held in the homes two weeks after baseline and follow-up data collected three months later. Interviews with managers explored their views of the feedback and recorded any changes that had been made because of it.

RESULTS

Participant recruitment was challenging, despite working in partnership with the homes. Resident response rates ranged from 23 to 54 % with 58 residents from four care homes taking part in the research. 53 % lacked capacity to consent. Inter-rater reliability for the ASCOT ratings of SCRQoL were good at time one (IRR = 0.72) and excellent at time two (IRR = 0.76). During the study, residents' ability to perform activities of daily living declined significantly (z = -2.67, p < .01), as did their expected needs in the absence of services (z = -2.41, p < .05). Despite these rapid declines in functionings, residents' current SCRQoL declined slightly but not significantly (Z = -1.49, p = .14). Staff responded positively to the feedback given and managers reported implementing changes in practice because of it.

CONCLUSION

This exploratory study faced many challenges in the recruitment of residents, many of whom were cognitively impaired. Nevertheless, without a mixed-methods approach many of the residents living in the care homes would have been excluded from the research altogether or had their views represented only by a representative or proxy. The value of the mixed-methods toolkit and its potential for use by providers is discussed.

Predictors of loneliness among older women and men in Sweden: A national longitudinal study

OBJECTIVES

Longitudinal research on loneliness in old age has rarely considered loneliness separately for men and women, despite gender differences in life experiences. The objective of this study was to examine the extent to which older women and men (70+) report feelings of loneliness with a focus on: (a) changes in reported loneliness as people age, and (b) which factors predict loneliness.

METHOD

Data from the 2004 and 2011 waves of SWEOLD, a longitudinal national survey, was used (n = 587). The prediction of loneliness in 2011 by variables measured in 2004 and 2004-2011 variable change scores was examined in three logistic regression models: total sample, women and men. Variables in the models included: gender, age, education, mobility problems, depression, widowhood and social contacts.

RESULTS

Older people moved into and out of frequent loneliness over time, although there was a general increase in loneliness with age. Loneliness at baseline, depression increment and recent widowhood were significant predictors of loneliness in all three multivariable models. Widowhood, depression, mobility problems and mobility reduction predicted loneliness uniquely in the model for women; while low level of social contacts and social contact reduction predicted loneliness uniquely in the model for men.

CONCLUSION

This study challenges the notion that feelings of loneliness in old age are stable. It also identifies important gender differences in prevalence and predictors of loneliness. Knowledge about such differences is crucial for the development of effective policy and interventions to combat loneliness in later life.

Assessing the physical environment of older people's residential care facilities: development of the Swedish version of the Sheffield Care Environment Assessment Matrix (S-SCEAM)

Background

There is emerging evidence that the physical environment is important for health, quality of life and care, but there is a lack of valid instruments to assess health care environments. The Sheffield Care Environment Assessment Matrix (SCEAM), developed in the United Kingdom, provides a comprehensive assessment of the physical environment of residential care facilities for older people. This paper reports on the translation and adaptation of SCEAM for use in Swedish residential care facilities for older people, including information on its validity and reliability.

Methods

SCEAM was translated into Swedish and back-translated into English, and assessed for its relevance by experts using content validity index (CVI) together with qualitative data. After modification, the validity assessments were repeated and followed by test-retest and inter-rater reliability tests in six units within a Swedish residential care facility that varied in terms of their environmental characteristics.

Results

Translation and back translation identified linguistic and semantic related issues. The results of the first content validity analysis showed that more than one third of the items had item-CVI (I-CVI) values less than the critical value of 0.78. After modifying the instrument, the second content validation analysis resulted in I-CVI scores above 0.78, the suggested criteria for excellent content validity. Test-retest reliability showed high stability (96% and 95% for two independent raters respectively), and inter-rater reliability demonstrated high levels of agreement (95% and 94% on two separate rating occasions). Kappa values were very good for test-retest (κ = 0.903 and 0.869) and inter-rater reliability (κ = 0.851 and 0.832).

Conclusions

Adapting an instrument to a domestic context is a complex and time-consuming process, requiring an understanding of the culture where the instrument was developed and where it is to be used. A team, including the instrument’s developers, translators, and researchers is necessary to ensure a valid translation and adaption. This study showed preliminary validity and reliability evidence for the Swedish version (S-SCEAM) when used in a Swedish context. Further, we believe that the S-SCEAM has improved compared to the original instrument and suggest that it can be used as a foundation for future developments of the SCEAM model.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2318-15-3) contains supplementary material, which is available to authorized users.

Using structured observation and content analysis to explore the presence of older people in public fora in developing countries

There is a lack of research on the everyday lives of older people in developing countries. This exploratory study used structured observation and content analysis to examine the presence of older people in public fora and considered the methods' potential for understanding older people's social integration and inclusion. Structured observation occurred of public social spaces in six cities each located in a different developing country and in one city in the United Kingdom, together with content analysis of the presence of people in newspaper pictures and on television in the selected countries. Results indicated that across all fieldwork sites and data sources, there was a low presence of older people, with women considerably less present than men in developing countries. There was variation across fieldwork sites in older people's presence by place and time of day and in their accompanied status. The presence of older people in images drawn from newspapers was associated with the news/non-news nature of the source. The utility of the study's methodological approach is considered, as is the degree to which the presence of older people in public fora might relate to social integration and inclusion in different cultural contexts.

Coping style and quality of life in elderly patients with vision disturbances

Purpose. This study aims at evaluating coping style and quality of life in patients with glaucoma and cataract. Methods. The participants were patients (N = 237, 130F; mean age: M = 67,8; SD = 9,5) with low vision caused by cataract (N = 188) and glaucoma (N = 49) who answered the Quality of Life Questionnaire (QOLQ) by Schalock and Keith. The participants were divided by means of cluster analysis (k-means) according to coping styles measured by CISS (Endler and Parker) into three groups: (1) high mobilization for coping, (2) task-oriented coping, and (3) low mobilization for coping. Results. In all the group, a general quality of life was moderately lowered; however, in task-oriented group it was relatively high. Moreover, task-oriented group had significantly lower level of anxiety (STAI), hopelessness (HS), and loneliness (UCLA LS-R) and higher level of self-esteem (SES) in comparison to the patients from high mobilization and low mobilization for coping. Conclusions. In an old age, adaptive coping with vision disturbances does not necessarily mean flexibility in combining all coping styles, but rather task-oriented coping and an ability to use social support. Extreme mobilization for coping seems not adaptive similarly like low mobilization for coping because it violates balance between environmental requirements and personal resources.

Whole home exercise intervention for depression in older care home residents (the OPERA study): a process evaluation

BACKGROUND

The 'Older People's Exercise intervention in Residential and nursing Accommodation' (OPERA) cluster randomised trial evaluated the impact of training for care home staff together with twice-weekly, physiotherapist-led exercise classes on depressive symptoms in care home residents, but found no effect. We report a process evaluation exploring potential explanations for the lack of effect.

METHODS

The OPERA trial included over 1,000 residents in 78 care homes in the UK. We used a mixed methods approach including quantitative data collected from all homes. In eight case study homes, we carried out repeated periods of observation and interviews with residents, care staff and managers. At the end of the intervention, we held focus groups with OPERA research staff. We reported our first findings before the trial outcome was known.

RESULTS

Homes showed large variations in activity at baseline and throughout the trial. Overall attendance rate at the group exercise sessions was low (50%). We considered two issues that might explain the negative outcome: whether the intervention changed the culture of the homes, and whether the residents engaged with the intervention. We found low levels of staff training, few home champions for the intervention and a culture that prioritised protecting residents from harm over encouraging activity. The trial team delivered 3,191 exercise groups but only 36% of participants attended at least 1 group per week and depressed residents attended significantly fewer groups than those who were not depressed. Residents were very frail and therefore most groups only included seated exercises.

CONCLUSIONS

The intervention did not change the culture of the homes and, in the case study homes, activity levels did not change outside the exercise groups. Residents did not engage in the exercise groups at a sufficient level, and this was particularly true for those with depressive symptoms at baseline. The physical and mental frailty of care home residents may make it impossible to deliver a sufficiently intense exercise intervention to impact on depressive symptoms.

Creativity and dementia: Does artistic activity affect well-being beyond the art class?

The Alzheimer’s Association’s Memories in the Making® (MIM) art activity program is intended to enhance the well-being of individuals who are living with dementia. Previous evaluations of MIM have found that participants show benefits on several well-being domains measured by the Greater Cincinnati Chapter Well-Being Observation Tool©. The current study extended those findings by looking for evidence of carry-over effects beyond the temporal boundaries of MIM sessions. Additionally, this study evaluated key psychometric qualities of the assessment instrument. Seventy-six MIM participants with middle- to late-stage dementia were evaluated by interns and care facility staff at the beginning, middle and end of a 12-week MIM program. Interns focused on behavior within MIM sessions and staff rated functioning outside MIM sessions. Staff reported no significant changes in resident well-being across the 12-week program. Interns reported significant improvements from the beginning to middle and end of the program on five well-being domains. Psychometric analyses of the Greater Cincinnati Chapter Well-Being Observation Tool© identified weaknesses in inter-rater reliability and found that the instrument measures two orthogonal factors – interpreted as ‘Well-Being’ and ‘Ill-Being’ – not the seven domains claimed. Quantitative evidence for the effectiveness of MIM is ambiguous, but anecdotal observations indicate that the program is beneficial for some participants, if only fleetingly.

Quality of life in older people: a structured review of self-assessed health instruments

A range of terms (including quality of life, health-related quality of life and health status) describe a broad set of aspects of self-reported health that can be captured by questionnaires and related instruments. Health in older people particularly requires attention to broader aspects of the impact of health on physical, social and psychological function. A structured review was performed to assess how well such issues are measured by available instruments. A total of 45 instruments were identified that have received some degree of evaluation to establish their use in assessing the health of older individuals. Two types of instruments were included in the review: generic and older-people-specific instruments. The SF-36 has by far the largest evidence base to support its use in older people. The OMFAQ has the best evidence base amongst older-people-specific instruments. Many instruments have only minimal evidence of measurement properties. Concepts such as quality of life are still defined and used in a variety of ways, and major questions must be addressed before uniform practice emerges in this important area of health policy.

Solid organ transplantation: technical progress meets human dignity: a review of the literature considering elderly patients' health related quality of life following transplantation

INTRODUCTION

Many transplant studies in elderly patients focus on survival and mortality rates. It was the aim of this review to evaluate publications dealing with individual patient performance and independence.

METHODS

The literature search included all articles retrievable for the hit "transplantation in elderly recipients" between 1960 and 2010. For quality search the inclusion criteria were as follows: older than 60 years and transplanted kidney, liver, heart, lung or pancreas from a deceased or living donor. We focussed on parameters concerning quality of life, frailty, nutritional status/weight loss, drugs/interactions/polypharmacy, gait/osteoporosis/fracture, delirium/dementia and geriatric assessment to address physical and psychosocial functionality of elderly recipients.

RESULTS

The initial hit list contained 1427 citations from electronic databases. 249 abstracts thereof were selected for full review. A total of 60 articles met final inclusion criteria. Finally, only five studies met the qualitative inclusion criteria as listed above.

CONCLUSION

The number of elderly patients placed on waiting lists has increased dramatically and will further grow. Interdisciplinary collaboration and distinct patient selection is recommended in most of the studies. However, data concerning quality of life and related parameters in elderly transplant recipients are rare.

The contribution of home-based technology to older people's quality of life in extra care housing

Background

British government policy for older people focuses on a vision of active ageing and independent living. In the face of diminishing personal capacities, the use of appropriate home-based technology (HBT) devices could potentially meet a wide range of needs and consequently improve many aspects of older people's quality of life such as physical health, psychosocial well-being, social relationships, and their physical or living environment. This study aimed to examine the use of HBT devices and the correlation between use of such devices and quality of life among older people living in extra-care housing (ECH).

Methods

A structured questionnaire was administered for this study. Using purposive sampling 160 older people living in extra-care housing schemes were selected from 23 schemes in England. A face-to-face interview was conducted in each participant's living unit. In order to measure quality of life, the SEIQoL-Adapted and CASP-19 were used.

Results

Although most basic appliances and emergency call systems were used in the living units, communally provided facilities such as personal computers, washing machines, and assisted bathing equipment in the schemes were not well utilised. Multiple regression analysis adjusted for confounders including age, sex, marital status, living arrangement and mobility use indicated a coefficient of 1.17 with 95% CI (0.05, 2.29) and p = 0.04 [SEIQoL-Adapted] and 2.83 with 95% CI (1.17, 4.50) and p = 0.001 [CASP-19].

Conclusions

The findings of the present study will be value to those who are developing new form of specialised housing for older people with functional limitations and, in particular, guiding investments in technological aids. The results of the present study also indicate that the home is an essential site for developing residential technologies.

The OPERA trial: a protocol for the process evaluation of a randomised trial of an exercise intervention for older people in residential and nursing accommodation

Background

The OPERA trial is large cluster randomised trial testing a physical activity intervention to address depression amongst people living in nursing and residential homes for older people. A process evaluation was commissioned alongside the trial and we report the protocol for this process evaluation. Challenges included the cognitive and physical ability of the participants, the need to respect the privacy of all home residents, including study non-participants, and the physical structure of the homes. Evaluation activity had to be organised around the structured timetable of homes, leaving limited opportunities for data collection. The aims of this process evaluation are to provide findings that will assist in the interpretation of the clinical trial results, and to inform potential implementation of the physical activity intervention on a wider scale.

Methods/design

Quantitative data on recruitment of homes and individuals is being collected. For homes in the intervention arm, data on dose and fidelity of the intervention delivered; including individual rates of participation in exercise classes are collected. In the control homes, uptake and delivery of depression awareness training is monitored. These data will be combined with qualitative data from an in-depth study of a purposive sample of eight homes (six intervention and two control).

Discussion

Although process evaluations are increasingly funded alongside trials, it is still rare to see the findings published, and even rarer to see the protocol for such an evaluation published. Process evaluations have the potential to assist in interpreting and understanding trial results as well as informing future roll-outs of interventions. If such evaluations are funded they should also be reported and reviewed in a similar way to the trial outcome evaluation.

Trial Registration

ISRCTN No: ISRCTN43769277

QUALIDEM: development and evaluation of a dementia specific quality of life instrument--validation

OBJECTIVE

To validate the QUALIDEM, a quality of life measure for people with dementia within residential settings rated by professional caregivers.

METHOD

In a sample of 202 residents of nursing homes Spearman rank correlations were calculated between the QUALIDEM subscales aand indices of convergent validity and discriminant validity, with dementia severity and need of care, with global QOL scores by the head nurse and family, and with self-report on COOP/WONCA Charts.

RESULTS

The one-method multi-trait matrix showed 90.5% of the correlations to be in support for convergent and discriminant validity. Low to moderate correlations were observed with dementia severity and need of care, confirming that QOL is not merely disease severity. Support for concurrent validity was found in correlations with QOL ratings by the head nurse. The QUALIDEM did not correlate with most of the family ratings or with the COOP/WONCA Charts.

CONCLUSION

The results of this validation study together with the obtained content validity through the method of construction provide sufficient support for validity of the QUALIDEM to be used for care evaluation and research in residential settings.

Quality of life demands comprehension and further exploration

The intention of this study was to elucidate what the concept "quality of life" means to elderly women. A qualitative approach based on 282 women (age 75-93 years) showed that the participants were able to articulate what quality of life meant to them. Thinking about what makes for a good quality of life, 82.3% mentioned the importance of good social functioning, 68.8% mentioned good health, 22.3% mentioned good economic circumstances, and 14.9% mentioned the importance of living in their own flat or house. Six categories were identified based on the women's descriptions: holism, relationships, activity and participation, pragmatic approach to health, belonging and social environment, and personal values. The lay perspective on quality of life is characterized by three qualities: preservation of continuity-sameness within change, power-empowerment, and the quest for meaning.

Dementia Care Mapping: A Review of the Research Literature

PURPOSE

The published literature on dementia care mapping (DCM) in improving quality of life and quality of care through practice development and research dates back to 1993. The purpose of this review of the research literature is to answer some key questions about the nature of the tool and its efficacy, to inform the ongoing revision of the tool, and to set an agenda for future research.

DESIGN AND METHODS

The DCM bibliographic database at the University of Bradford in the United Kingdom contains all publications known on DCM (http://www.bradford.ac.uk/acad/health/dcm). This formed the basis of the review. Texts that specifically examined the efficacy of DCM or in which DCM was used as a main measure in the evaluation or research were reviewed.

RESULTS

Thirty-four papers were categorized into five main types: (a) cross-sectional surveys, (b) evaluations of interventions, (c) practice development evaluations, (d) multimethod evaluations, and (e) papers investigating the psychometric properties of DCM.

IMPLICATIONS

These publications provide some evidence regarding the efficacy of DCM, issues of validity and reliability, and its use in practice and research. The need for further development and research in a number of key areas is highlighted.

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

The changing demographic profile of the world's population towards old age and evidence of people living for longer with less time spent in ill health highlight the importance of addressing quality-of-life (QOL) assessment issues for older people. The assessment of health-related QOL (HR-QOL) has received considerable attention in the last 2-3 decades, with a wide variety of assessment instruments available. These instruments can be either generic or disease specific, health profiles or preference based. The literature was reviewed systematically to identify studies measuring HR-QOL in older patient groups. A total of 37 studies were identified, 11 of which were randomised, controlled trials/evaluations, 14 were prospective studies that did not involve a randomised, controlled intervention, and 12 were cross-sectional studies. Studies were summarised in terms of the study aim, patient population characteristics, the instrument used to measure HR-QOL, and HR-QOL findings. A majority of studies used a generic HR-QOL instrument, the single most commonly used being the 36-Item Short-Form Health Survey. In many cases, a second disease-specific measure was used in combination with the generic measure. In a majority of studies involving interventions, significant improvements in HR-QOL were noted. In prospective studies, a negative impact of health conditions (e.g. myocardial infarction and chronic heart failure) was also identified using HR-QOL assessments. None of the studies in this review used HR-QOL measurement instruments that were old-age specific. Using instruments that are not specific to a particular age group enables comparisons to be made with other age groups, i.e. younger or middle-aged groups. However, the questionnaire items of HR-QOL instruments tend to be phrased predominantly in relation to physical function and thus may inadvertently discriminate against older persons, whose physical function is likely to be not as good as that of younger people. Particular issues in the assessment of HR-QOL in older patient populations include the persistent finding of a poor relationship between QOL and disability/disease severity, the dynamic nature of QOL, and the importance of valid proxy ratings for those unable to make decisions or communicate for themselves. It is important, therefore, that assessment of HR-QOL incorporates issues of importance to individual older people by broadening the scope of the measurement instruments, thus representing more validly the HR-QOL status of older patient groups. Future research in HR-QOL must incorporate the perspective of the individual in order to enable valid conclusions to be derived based on content that is relevant to the individual being assessed, thus informing management decisions, policy and practice more meaningfully.

Is quality of life a healthy concept? Measuring and understanding life experiences of older people

The concept of quality of life has received considerable attention as an inclusive notion of health and as a basis for health interventions. The authors' argument in this article is that notwithstanding this attention, little consensus exists as to definition of the term. In addition, a focus on measurement has led to the neglect of wider aspects of quality of life. Such difficulties are particularly relevant to the study of quality of life of older people. Analysis of interview data suggests that older people's understandings of quality of life are not readily measurable and should be viewed in terms of phenomenological experience. The authors discuss the implications for studying quality of life of this group and difficulties for the concept itself.