Does the institutionalization influence elderly’s quality of life? A systematic review and meta–analysis

The elderly population is growing worldwide in greater rates [1], as a result of increased longevity and lower mortality rates [2, 3]. In view of this, there is a concern about the active aging process, in which the continuing participation of aged people on daily activities is enhanced [4]. Active aging refers to keep elderly health and on the control of their daily activities. This may generate better Quality of Life (QoL) [5], represented by favourable perceptions of their position in life, within a cultural context, in relation to their goals, expectations, concerns and desires [6]. Therefore, active aging refers to the physical, social and mental well-being, as well as, social participation, protection, safety, and care of the elderly to avoid disabilities, chronic diseases and less use of health care services [4].

Although the importance of active aging and better QoL for the elderly is evident, there is a lack of family care, which increases the elderly’s institutionalization and, by consequence, increase the number of community-dwelling aged people who became residents of nursing homes [7]. Advance age, not having a home or a partner, low educational level, sedentary lifestyle, poor self-rated health status, high number of drug prescriptions and functional and cognitive impairments are the main predictors of the institutionalization process [7, 8]. In addition, the lack of support and assistance to the elderly during daily activities is suggested as an aggravating factor for stimulating elderly’s institutionalization [7].

Considering the raised institutionalization rates, nursing homes should provide good quality of life for their residents [9]. In this sense, studies [10‐25] sought to understand if lives in homes for the aged may influence the elderly’s QoL. Thereby, worse QoL was observed in elderly residents of long-term care institutions, in comparison with community-dwelling individuals [11, 13, 16‐19, 22, 23, 25]. In addition, the literature has shown that the elderly residing in nursing homes or institutionalized elderly have lower educational level [13, 25], poorer health status [13, 25], higher dependency level [18], higher risk of falls [18], lower physical activity [18, 22], lower decision-making ability [23], lower leisure activities [25] and are older [13, 25].

In contrast, a study found better QoL of institutionalized elderly men compared to the non-institutionalized elderly in physical and psychological domains [15], which was attributed to the multidisciplinary professional team offering support and stimulus to the institutionalized elderly. Other studies did not find differences in the QoL between institutionalized elderly and non-institutionalized elderly [14, 20]. Finally, divergent results, from different QoL questionnaire domains were observed between institutionalized and non-institutionalized elderly [10, 12, 21, 24].

Considering this, it is important solve such controversies in order to know if the institutionalization influence the QoL and in which domains. Thus, this knowledge can support the homes for the aged in performing actions and better care for the elderly in view of the promotion of a good QoL for these individuals. Therefore, the purpose of this systematic review and meta-analysis was to summarize these findings and verify the influence of institutionalization on the elderly’s general health and oral health related QoL.

The process of population aging is a global phenomenon that must be accompanied by the physical, psychological, social, economic and spiritual well-being of the elderly [6]. As a result of this aging process and the unavailability of family members to care for the elderly, the institutionalization of these individuals has increased [7]. In this sense, the homes for the aged should be able to provide good quality of life for their residents [9]. In contrast, this systematic review summarized that the institutionalization affects the QoL of elderly individuals.

In our systematic review, of 16 studies included, 15 [10‐23, 25] were conducted in developing countries, and of these studies, seven were performed in Brazil [11, 14‐16, 19, 21, 25]. In developed nations, the need for nursing homes is reduced due to the care given to the elderly by the State and the family, as well as the high purchasing power of the population that allows the elderly to remain in their homes receiving the health care they need [7, 8]. Moreover, in these countries the institutionalization of the elderly is related to the presence of specific health conditions such as dementia, Alzheimer’s disease or cognitive disorders [7]. On the other hand, in the developing countries there is a high rate of institutionalization of the elderly due to cultural, economic and family factors [8]. In this context, identifying differences in QoL of institutionalized older people compared to non-institutionalized ones has been shown to be of interest in studies in developing countries, especially in Brazil.

In the same way, most of the study participants were elderly with 60 years old or more, which is in accordance with the definition by World Health Organization (WHO) and United Nations. Inconsistently, two studies were against this classification [14, 20]. Kuok et al. (2017) and Bonan et al. (2008) included a cut-off level of 50 and 55 years old, respectively. The first study [20] selected 451 participants, of which 248, were residents of nursing homes with a mean age of 78.4 (+/− 8.3) years old, and the other 203 were community dwelling elderly, aged 64.1 (+/− 6.8) years old. The latter research [14] included elderly aged 70.3 (+/− 10.2 years). Both studies revealed that a small number of participants had less than 60 years and those were not institutionalized [14, 20]. Moreover, no differences have been observed on QoL of elderly from long-term care institutions when compared to community dwelling ones [14, 20], reaffirming that ages < 60 years did not compromise their results. Therefore, whereas the sample size of Kuok et al. (2017) and Bonan et al. (2008) was uniquely included in our qualitative assessments (not included in meta-analysis), both studies were kept in this systematic review, not impairing the results.

The effects of aging process with regards to general health perceptions, physical, psychological social and environment domains can be verified by means of QoL questionnaires [6]. Although it is considered a subjective and complex evaluation, the QoL has been extensively studied among elderly, once the perception of life changes during aging process and is influenced by individual’s perspectives about life and society [33]. Therefore, some questionnaires have been used to assess HRQoL, as example of Leipad, WHOQOL-BREF, WHOQOL-OLD, SF-36, RAND-36, and OHRQoL as GOHAI.

The Leipad questionnaire comprises of 49 self-assessed items grouped in seven core domains: self-care, physical, cognitive, social and sexual functions, depression and anxiety and life satisfaction [34]. Two eligible studies [10, 24] were submitted to a meta-analysis and identified better QoL in institutionalized elderly, when compared to the non-institutionalized elderly, in the “cognitive functions” and “depression and anxiety”. It can be hypothesized that institutionalized elderly accepts and get used to an institutionalized life along time [24]. Since there is an increase on social interaction, communicative activities, and performance of cognitive exercises, depression and anxiety symptoms drastically decrease [10]. All these factors contribute to maintain elderly’s cognitive function, which improves QoL [10, 24].

Indeed, when Leipad domains were analysed together, no differences have been found on the QoL of the institutionalized elderly compared to the non-institutionalized. This result may be attributed to the low power of certainty of scientific evidence of the studies [10, 24] due to the incompatibility between groups in relation to age, gender, socioeconomic conditions and comorbidities, the non-reduction of these characteristic discrepancies on statistical analysis [10] and insufficient sample size [24].

The WHOQOL questionnaire is an international recognized instrument from WHO to evaluate QoL. Besides the extended version (WHOQOL-100) [35], there is an abbreviated (WHOQOL-BREF) [36] and a specific version to evaluate elderly’s QoL (WHOQOL-OLD) [37]. The WHOQOL-BREF contains 26 items grouped in four domains: physical, psychological, environmental and social [36], while WHOQOL-OLD comprises of 24 items subdivided into 6 domains: sensorial ability, autonomy, past, present and future activities, social participation, death and dead, intimacy [37].

Regarding meta-analysis using WHOQOL-BREF questionnaire [12, 15, 17, 20, 25], institutionalized elderly presented worse QoL in all domains as well as in the pooled results when compared to the non-institutionalized group. In relation to the physical domain, the differences can be explained by the insufficient promotion of physical activities between elderly in long-term care institutions, or their lack of engagement on social activities, aggravated by serious systemic diseases [13, 15, 20]. These individual health conditions aggravate the sedentary lifestyle, compromising the elderly functional capacity and physical health [20, 25]. Also, the absence of physical activity can lead to the development of depressive symptoms, explaining the worse QoL found in psychological domain for institutionalized elderly when compared to community dwelling ones [20, 25].

Depression is a prevalent disease in institutionalized elderly and a predictor of a worse QoL in social domain [20]. In addition, the physical distance between elderly and family, relatives and friends impair their social life and, consequently, their perception about QoL on the social domain [13, 16, 17], exposing the worse QoL found in institutionalized elderly. Nevertheless, elderly are constantly sheltered against their own desire and do not receive family visits, contributing to the isolation [16, 25]. Another important aspect that compromises QoL on social domain of institutionalized elderly is the lack of opportunity to accomplish leisure activities, which impacts on social environment and social contact between these individuals [25].

In addition, the absence of socialization is directly related to the deterioration of physical and mental health of institutionalized elderly, accounting for the worse QoL on physical and psychological domains when compared to the community dwelling [25]. Finally, differences on environmental domain describes the negative feeling of elderly concerning the distance from their home, and the difficult to adapt to the new and unfamiliar place of residence [13].

Still, the differences on QoL found between institutionalized and community dwelling elderly must be observed with caution due to the risk of bias and the low certainty of evidence of included studies. Bodur and Cingil (2009), Dagios et al. (2015) and Vitorino et al. (2013) did not paired the age between groups, then institutionalized elderly were older than the non-institutionalized group. However, there is a relation between age increment and declined QoL of elderly on psychological, social and environmental domains [13]. Therefore, the discrepancy of age in that studies [13, 16, 25] may have affected the meta-analysis results.

In addition, WHOQOL-BREF should be used simultaneously with the WHOQOL-OLD when the QoL of elderly people is being evaluated to improve the data collection and get more precise results. Despite this, only one article [16] have adopted both, whereas some authors [13, 15, 17, 20, 25] preferred to apply one of the versions, perhaps as a way to shorten the data collection. Moreover, although the use of WHO questionnaires requires attention to fill all items correctly, of the studies that used WHOQOL-BREF questionnaire, two [17, 25] applied this instrument by more than one interviewer, which could have under or overestimate the answers, which may account to the risk of biased results.

A meta-analysis of the studies that used WHOQOL-OLD questionnaire [16, 23] demonstrated on “past, present and future activities”, “intimacy”, “social participation” and “sensory abilities” domains, as well as for pooled results, worse QoL for the institutionalized elderly than for the non-institutionalized ones. The term “past, present and future activities” refers to the satisfaction with the future, the desired opportunities, and recognition with what has been achieved throughout life [37]. It is known that the great majority of the elderly are not freely institutionalized of their own, but rather by family decision [16]. This finding suggests that the elderly consider that being institutionalized is not what they hoped to have achieved in life, and that there are no opportunities to change this reality [16].

The ‘intimacy’ domain included questions about the sense of fellowship and love in life, and as opportunities to love and be loved. By any means, there is a prevalence of widowed, separated or single institutionalized elderly, that is, they do not have a partner, unlike the community dwelling elderly who are mostly married [17]. This explains the finding that the institutionalized elderly felt less satisfied about the companionship and love received than the non-institutionalized elderly. The satisfaction with the use of time, activity accomplishment and participation in the community are evaluated in the ‘social participation’ facet [37]. Thus, elderly residing in nursing homes cause a feeling of being prevented from carrying out their projects. This way, distance from family and friends also affects the social relations of these elderly, compromising their QoL in the ‘social participation’ domain [16].

At least, “sensory abilities” domain refers to the loss of sensory functioning in everyday life and in the ability to interact. In this context, institutionalized older people are more physically and sensorially incapacitated than the elderly living in the community [16, 23], confirming the results. Yet, these results might be interpreted with care, since the studies included in the meta-analysis refers to WHOQOL-OLD questionnaire [16, 23] presented methodological major problems that resulted in low certainty of scientific evidence.

The SF-36 and RAND-36 questionnaires comprises of 36 questions grouped in eight domains: physical functioning, role physical, bodily pain, general health perceptions, role emotional, vitality, mental health and social functioning [38, 49]. Although the SF-36 and Rand-36 instrument were considered a short form tool for health survey, both questionnaires represent a set of generic, coherent, and easily administered quality-of-life measurements [38, 39]. Furthermore, these instruments were used for several studies to assess health related QoL [18, 22, 23].

Considering the equality of the domains and the overall scale of these questionnaires and that they only differ slightly in the scoring method [39], the studies [18, 22, 23] that used SF-36 and RAND-36 questionnaires to evaluated the QoL were grouped in the same meta-analysis, in order to the quantitative synthesis was able to be performed. This meta-analysis demonstrated that the institutionalized elderly presented worse QoL than non-institutionalized elderly for “physical functioning” domain and pooled results. It brings out that the raised prevalence of health problems, such as degenerative joint disease [13], especially in institutionalized elderly limit the performance of physical activities.

However, SF-36 “physical functioning” domain evaluates the performance of vigorous activities that elderly generally cannot execute [40]. Possibly, questions within this domain do not measure accurately the performance of elderly with a poor systemic health [40], which is the case of the institutionalized elderly. All factors may have influenced the results found in the studies using SF-36 questionnaire [18, 22]. In addition, the study of Rachadel et al. (2015) the elderly who lived in nursing homes presented higher mean age than the non-institutionalized. This methodologic problem may affect the findings since the aging process is related to worse QoL of elderly [13].

Apart from the previous findings, the comparation of the OHRQoL between institutionalized elderly and community-dwelling elderly has not been frequently evaluated in the studies. Instead, only a few reports [11, 14] evaluated OHRQoL and revealed sparse results for institutionalized elderly when compared to the non-institutionalized elderly. Due to insufficient data, the meta-analysis did not include these two studies. Even though, the relevance of oral health conditions must be enhanced in further analysis, as the presence of teeth or prosthetic treatment improves self-steam and increase masticatory functions and, consequently, the elderly QoL [41‐43].

Finally, it is essential to mention the limitations of the present systematic review, especially those concerning the different methodological measurements, the wide range of age, culture and gender found in the included studies. These limitations could be the main reason of the high heterogeneity [28, 31]. Therefore, our outcomes should be carefully observed, as it may not impact the elderly’s QoL worldwide. However, although the included studies used different questionnaires to assess the QoL, separate meta-analyzes were performed for each questionnaire [30] and the standardized mean difference was used when the studies measure the QoL in different scales [31]. These procedures were realized in order to minimize risk of bias and try to ensure the accuracy of the results.

The wide range of age could be explained due to most of the included studies were conducted in underdeveloped countries, where the mean age of elderly is lower than in developed countries [3] and the nursing homes do not have an age limit to admit people. Furthermore, the discrepancies of age, gender and culture is inherent to where and how the studies were conducted. Another limitation is the publication bias, which is the tendency of journals to publish positive results over negative evidence [28]. Thus, positive results of institutionalization over elderly’s QoL could have been found but never published before, which may bias the outcomes of this systematic review. In order to minimize this bias, we tried to identify unpublished works in SIGLE, in meetings and through contact with experts [28].

Nevertheless, although well-designed primary studies should be conducted to generate robust scientific studies to support the meta-analysis, no other review has been compiled data concerning QoL of institutionalized elderly and non-institutionalized elderly in the literature. Therefore, the outcomes of this study will help on guiding the creation of specific public health policies to the nursing homes. Regarding the low QoL found for institutionalized elderly, it is important to mention that health care must be provided and integrated to social services to ensure that dependent people keep the highest possible QoL [4]. Specialized professionals can be hired to work in nursing homes, according to the needs of each place, such as physical educators, physiotherapists, nutritionists, dentists, psychologists and medical doctors. Moreover, improving caregivers training and the infrastructure conditions guarantee QoL to the residents in physical, psychological, social and environmental aspects, and create an integrated environment where elderly could live with fairness, dignity, participation, respect and autonomy [9].

The institutionalization influences negatively the QoL of the elderly. However, this should be approached with caution, due to the presence of methodological bias in the articles assessed in this systematic review, which consequently resulted in poor quality of evidence. Therefore, further primary and well delineated studies should be accomplished to confirm this evidence.