Background
Although frailty is often described as merely a physical construct [
1], there is a growing tendency to conceptualize frailty from a multidimensional perspective, where environmental, psychological, and social factors are taken into account as well [
2]. Prevalence rates of multidimensional frailty vary between 4.2–59.1% across studies, depending on the definition and the population included [
3]. Multidimensional frailty is associated with higher age [
3,
4] and may lead to disability, hospitalization, early institutionalization, and death [
5,
6]. Hence, it might threaten the wish most older people have to age in place [
7]. Moreover, aging in place is stimulated from a policy perspective, for example to reduce the overall costs of institutionalization [
8]. Early detection and prevention of frailty are important topics for research, policy, and clinical practice because of the growing number of people aged 65 years and over [
9], the negative consequences of frailty, and the necessity of enabling aging in place.
Current approaches on frailty seem to be dominated by a “deficit approach.” They mainly focus on things people cannot do any longer and the risks of adverse outcomes [
5,
6], or define frailty as an accumulation of deficits [
10]. Despite this deficit approach in research, older people themselves seem less focused on shortages. A recent qualitative study showed that older people favor receiving support that improves their autonomy and well-being, instead of interventions which focus on diseases and dysfunctions [
11,
12]. Besides, older people dislike an approach in which every older adult is perceived as someone with (a risk of) deficits [
11]. Furthermore, qualitative studies revealed negative consequences of stereotyping. For example, when people were labeled as frail by others, this actually made them feel frail, and they behaved accordingly [
13]. This suggests that a strengths-based approach, which offers the opportunity to get a better understanding of people’s strengths and abilities [
14,
15], might be of value for frailty prevention strategies.
As frail older people still can have a good perceived quality of life (QoL), this might be an important entry for such a strengths-based approach. For example, previous research has shown that nearly 50% of the participants who were frail at least on the physical domain still reported a good to excellent QoL [
16]. In another study, 46% of physically frail older women reported a good QoL [
17], while in a qualitative study 8 out of 11 frail participants reported a satisfactory to good QoL [
18]. Qualitative studies that have investigated what QoL means to (frail) older people revealed several important factors: social contacts, (physical) health, psychological well-being, being able to perform activities, and having enough facilities at home and in the neighborhood [
18]. Nonetheless, little is known about factors that may actually contribute to a high QoL in frail older people. Although it has been found that frail older people with a higher age report higher levels of QoL [
19], as well as those who compare themselves with people in a worse situation [
18], the focus of these studies was not to identify strengths in frail older people. However, that is exactly what is important while aiming for a strengths-based approach.
The aim of this mixed-methods study was twofold: (1) to identify characteristics of community-dwelling, frail older people with higher and lower levels of QoL, respectively; and (2) to explain discrepancies in self-reported QoL, with a specific interest in identifying strengths that community-dwelling, frail older people with a higher QoL still have. Herewith, the focus was not on investigating associations between frailty and QoL, but on investigating which factors might explain differences in QoL among frail older people, as it seems particularly important to make (strength-based) interventions more tailored in this vulnerable population. While some studies assess multiple domains of QoL, this study focuses on overall QoL, which is defined as ‘an individual’s overall satisfaction with life and general sense of well-being’ [
20], and for which one question seems to be a particular adequate measure [
21].
Discussion
This mixed-methods study is the first aimed at identifying discrepancies between community-dwelling, frail older people with higher and lower levels of self-reported, overall QoL, focusing on potential strengths frail older people with higher levels of QoL still have. Despite similarities regarding perceived frailty or vulnerabilities according to the qualitative data, the quantitative data showed that people in the high QoL subgroup had lower levels of psychological frailty. In addition, higher age, higher levels of meaning in life (both quantitative data), having things in prospect, being of value/meaning to others, being able to cope with or adapt to difficulties, performing activities, and satisfaction with social network appeared to be factors that can distinguish frail older people with a higher QoL from those with a lower QoL. In addition, in the low QoL subgroup more unmet needs were experienced regarding factors important for QoL and meaning in life.
Participants in the high QoL subgroup seemed to have more effective ways of coping with and/or adapting to difficulties. For example, they focused on things they still were able to do, or replaced activities they were no longer able to perform. Indeed, previous research has shown that being able to cope with difficulties was important for life satisfaction in people aged 80 years and over who were assessed during and after rehabilitation [
30]. In addition, it has been found that disabled persons who were able to adapt reported higher levels of QoL compared to those who did not [
31], which is in line with our findings. Furthermore, both our quantitative and qualitative findings indicate that meaning in life is associated with QoL in frailty, along with having things in prospect. Related to this, previous research has shown that meaning in life contributes to QoL in people with chronic diseases [
32], while not having a purpose in life has been found to be associated with lower levels of QoL [
31]. Nonetheless, being able to cope and meaning in life have been found to be associated as well [
33]. Therefore, it could be argued that meaning in life is a part of the relationship between coping and QoL.
Although no clear differences were found in the qualitative interviews regarding the experienced level of frailty, while exploring the other quantitative findings, lower levels of psychological frailty were observed in the high QoL subgroup. Indeed, previous research has shown that feeling down, which is an important aspect of psychological frailty, is associated with lower levels of environmental, social, physical, and psychological QoL [
34]. In addition, psychological frailty has been found to predict past, present, and future activities [
35]. This could be related to our qualitative finding that frail older people with a higher QoL performed activities more often, while this was mentioned to be important for QoL in both subgroups. With regard to the finding that age might play an important role, previous research has found that being older was associated with a higher QoL in frailty as well [
19]. They argued that this could be due to the fact that older people had been able to adapt to their frailty. However, for the current study it is unknown whether participants in the high QoL subgroup indeed had been frail for a longer period of time than participants in the low QoL subgroup. Nonetheless, being able to adapt (e.g., by replacing activities one was no longer able to do) has been found to be important for higher levels of QoL.
Regarding QoL itself, previous research has already shown that psychological well-being, social contacts, and being able to perform activities are important aspects of QoL in older people [
18]. Indeed, these factors were mentioned to be important for QoL in this study as well. However, our findings add that these factors might actually be related to higher levels of QoL in frailty, as more unmet needs were mentioned in the low QoL subgroup. Whereas previous research has already shown that unmet needs are associated with lower levels of QoL [
36], this study identified specific unmet needs in frail older people with a lower QoL. For example, not having enough financial resources was only mentioned in the low QoL subgroup. While previous research has shown that financial resources had no significant effect on the association between frailty and well-being [
37], they have not investigated whether income actually fitted the needs of the older people, while this seems to be what is important according to our qualitative findings.
An unexpected finding might be that the majority of participants in both subgroups received (in) formal care as previous research has shown that support from informal caregivers enabled frail older people to maintain their well-being [
38]. We therefore would expect to see lower levels of (in) formal care in the low QoL subgroup. However, although both subgroups mentioned the social aspect to be important rather than the actual care they received from (in) formal caregivers, the low QoL subgroup less often pronounced that they actually felt supported by their social network, while this was one of the important aspects for higher levels of well-being in the previous study [
38].
Strengths and limitations
This study has several strengths. First of all, we adopted a mixed-methods design, and with the qualitative part we were able to explore experiences of frail older people more in-depth, taking a lot of different individual perspectives into account. Second, to reduce the risk of bias in personal interpretation, all interviews were coded independently by two researchers with different educational backgrounds, and group analyses were performed independently by two researchers as well. While author AvdV was involved in conducting the interviews and analyzing them in the first stage, author RV was an independent researcher who did not conduct any interviews nor was involved in the research project, to enable the trustworthiness of the findings. Lastly, by providing quotes in the results section, readers are enabled to interpret findings themselves.
However, this study has several limitations as well. First, the small sample size might have influenced quantitative findings, as the statistical power was relatively low. Second, only five participants in the low QoL subgroup (≤ 6) scored 5 or lower on QoL, and none below 4, whereas five participants in the high QoL subgroup (≥ 8) scored a 10. Therefore, the contrast between subgroups might be not as large as needed to distinguish substantial differences in people with lower and higher QoL levels. Third, QoL might fluctuate from day to day [
39], which was mentioned by one of the participants in the high QoL subgroup as well, but no repeated measures were conducted. Fourth, by assessing overall QoL with one overarching question, it could be argued that participants had different operationalization’s in mind [
40]. Nonetheless, overall QoL can be defined as ‘an individual’s overall satisfaction with life, and one’s general sense of personal wellbeing’ [
20,
21]. Fifth, informal caregivers were present during three interviews in the high QoL subgroup and during one interview in the low QoL subgroup, which might have influenced participants’ responses as they might have given socially desirable responses. Linked to this, an interpreter joined the interview in the case of language barriers (once in both subgroups), which might have affected the results as well [
41]. In addition, generalizability of findings is limited as only frail older people were included, although the frailest might have refused to take part. Lastly, participants in both subgroups had relatively low scores on the MoCA. However, a systematic review showed that in population-based cohorts many participants score below the cut-off of 26 for MCI, and it is argued that the threshold should be lower [
42]. In addition, we intended to include people at risk for frailty, which might explain these cognitive vulnerabilities.
Conclusion
Frail older people with a higher QoL seem to have better and more effective ways to cope with and/or adapt to difficulties. In addition, they report higher levels of meaning in life, seem to have more things in prospect, are older, have lower levels of psychological frailty, perform more activities, and are more satisfied with their social relationships compared to frail older people with a lower QoL. On the contrary, frail older people with lower levels of QoL report more unmet needs regarding their QoL and meaning in life.
Implications for future research
While this study aimed to identify individual perspectives and therefore was explorative, by means of a quantitative study approach it will be possible to examine whether for example coping strategies, having something in prospect, and meaning in life actually contribute to QoL in frailty on a larger scale. Hereby, a longitudinal study with repeated measures might be needed as QoL might change over time. Furthermore, future research should explicitly ask whether or not participants feel frail. Previous research has shown that older people who were classified as frail do not always perceive themselves as frail [
43], and “experienced frailty” may influence their self-reported QoL as well.
Implications for clinical practice
While current clinical practice in frailty mainly focuses on the prevention of negative outcomes, such as delaying functional decline [
44] or institutionalization [
45], results from this study suggest possibilities to promote and improve QoL by strengthening specific resources among frail older people. As older people indicate that they wish to focus on things they still can do [
11], such a strengths-based approach seems to be a promising way to work more preventatively. Therewith, clinical practice should focus on improving ways older people adapt to or cope with problems, psychological well-being, improving their meaning in life, making sure that people have something in prospect, and social contacts, as these factors contribute to QoL even in frailty. It is expected that this will contribute to aging in place with a good QoL.
Acknowledgments
The D-SCOPE consortium is an international research group and is composed of researchers from University of Antwerp, Vrije Universiteit Brussel, University College Ghent, Catholic University of Leuven, Belgium, and Maastricht University, the Netherlands: Peter Paul De Deyn, Liesbeth De Donder, Jan De Lepeleire, Ellen De Roeck, Nico De Witte, Eva Dierckx, Daan Duppen, Sarah Dury, Sebastiaan Engelborghs, Bram Fret, Lieve Hoeyberghs, Tinie Kardol, Gertrudis I.J.M. Kempen, Deborah Lambotte, Birgitte Schoenmakers, Jos M.G.A. Schols, An-Sofie Smetcoren, Michaël Van Der Elst, Anne van der Vorst, Dominique Verté, G.A. Rixt Zijlstra. The authors would like to thank all people who participated in the study.