Health-related quality of life among community-dwelling people aged 80 years and over: a cross-sectional study in France

The populations of industrialised countries have seen a major increase in the last few decades in the number of people living to a very old age. At present, 5.3% of the population in Europe is aged 80 years and over [1] and this age group is currently the fastest growing on the continent and will continue to be so up to 2050 [2]. To meet the challenges that come with this trend, one of the areas of interest explored in policies and services is to encourage living in the community until very old age. This is in line with the wishes of most older people in Western countries, who prefer to live in their own familiar environment as long as possible rather than in institutions [3‐5]. Such initiatives would also increase the ability of the health care systems to bear the financial costs [4]. However, owing to the great changes that occur in the long period of life that now extends beyond the age of 65, particularly in terms of health, particular attention needs to be paid to aged people’s quality of life (QoL). In 2014, total life expectancy at 65 years was 18.2 years, including 8.6 years with no activity restrictions for men, and 21.6 years, including 8.6 with no activity restrictions for women [6].

The quality of life is a broad concept covering all aspects of human activity. Health, the environment and social domain greatly influence the life of elderly people [4]. Health-related quality of life (HRQoL) is a reflection of the way that individuals perceive and react to their health-related factors, such as physical, functional, emotional, and mental well-being and to the nonmedical aspects of their lives such as family, friends and activities [7]. HRQoL and its determinants are therefore of interest to the individual from a medical and social point of view but also in shaping health policy [7]. Thus, measuring the HRQoL can be useful for studying some factors influencing housing decisions among elderly people and assessing how to act on these factors to promote the home support desired by the major part of elderly people and in the policies of many countries [5]. Measuring HRQoL of elderly people can also be useful when developing and then monitoring policy initiatives that are part of the dynamics of the Age-friendly Environments in Europe (AFEE) project [3]; for example by making it possible to assess the links between the physical or social environment and different dimensions of HRQoL. Precise and detailed HRQoL data from sufficiently large sample sizes of community-dwelling people aged 80 years are potentially of great interest but currently are scarce.

We assessed the HRQoL of community-dwelling elderly people (EP) aged 65 years and over in an earlier work [8] but, as in other studies, the number of participants aged 80 years and over was low (32 in our study) [9‐11]. Among other studies, a Brazilian team investigated the quality of life of a community-dwelling population aged 60 years and over using the WHOQOL-BREF and the WHOQOL-Old. Of the 317 participants recruited 15.4% were octogenarians but the study gave no specific results for this subgroup [12]. In Europe, the very few recent studies involving community-dwelling people aged 80 years and over, all used the generic EuroQol five dimension scale (EQ-5D). One assessed people aged 75 years and over in six European countries using in addition the SF-12 questionnaire [13]; another, conducted in Switzerland, assessed people aged 65 years and over of whom 41% were 80 years old or more [14]; and a third assessed Dutch people aged 65 years and over of whom 11.8% were octogenarians [15]. In three of these studies, data on comorbidities were scarce or lacking. To our knowledge no recent study assessing HRQoL using an instrument specifically aimed at EP has been made in European community-dwelling people aged 80 years and over.

To assess HRQoL in older people, specific instruments, which are more suitable than generic ones because of their item relevance and better acceptability, have been developed and provide particularly useful information. They allow an easy individual assessment of older people’s HRQoL and can be used for medical and psychosocial interventions, as described by Xiao-Jun Lin et al. [7] Some of them have shown particularly interesting psychometric properties [16]. They include the LEIPAD, an acronym derived from the first two of the three universities involved in its development, LEIden in the Netherlands and PADua in Italy, under the auspices of the European office of World Health Organization. The LEIPAD is a brief self-administered HRQoL questionnaire developed specifically for community-dwelling EP and validated for French speaking people aged 80 years and over [17, 18].

Thus, the aims of this original study were first to measure HRQoL in a larger sample of community-dwelling people aged 80 years or over using a self-administered questionnaire touching on various aspects of daily life specifically adapted to EP, the LEIPAD questionnaire, and second to study its association with sociodemographic and medical characteristics and life events of this age group.

This study makes two main contributions to the previous literature on HRQoL in EP. It is the first to assess the HRQoL of community-dwelling people aged 80 years and over (who are often few in number or absent from studies or whose age group is not studied specifically) with the use of a self-administered questionnaire specifically adapted to EP, the LEIPAD scale. In addition, it deals in detail with the comorbidities and life events of this age group and their relation to HRQoL.

Our study was guided by several important methodological aspects.

Some key points emerge from our study and are discussed in detail below: the declared HRQoL of EP aged 80 years of age and over was good for most dimensions but in certain domains was beginning to deteriorate, markedly so for the ‘Sexual Functioning’ scale; the female EP declared a significantly less satisfactory HRQoL in some domains; and some life events, other than health problems, negatively affected the HRQoL of EP in this age group.

The declared HRQoL of our study population was good for most dimensions but in certain domains was beginning to deteriorate. The best HRQoL score was obtained on the ‘Self-Care’ scale. This is an interesting finding because previous studies [13‐15] used EQ-5D, in which self-care has a significant ceiling effect [14, 32]. Our results are consistent with those of a French survey, Handicap Santé 2008 [33], that used other means of assessment and according to which life expectancy in France at 65 years with no restrictions of personal care activities was 15.6 years for men and 17.9 years for women. These concordant results can be explained by the fairly good autonomy of our community-dwelling participants, most of whom were able to eat meals, get dressed, take a bath or shower and do their shopping without assistance. Similar levels of autonomy were also observed in several French other surveys [27, 30, 34]. For the ‘Physical Function’ and the ‘Self-Care’ scales, a greater number of health problems and reported poor health during the previous 12 months negatively affected quality of life, which corroborates and complements previous data for these domains in studies of populations that were generally less elderly or that focused on specific diseases [11, 12, 35].

A large majority of the participants also had a good HRQoL score on the ‘Depression and Anxiety’ scale. The score was not correlated with age, as in five other studies [13‐15, 36, 37]. Our results are in line with those observed in the dimension of anxiety and depression in the EQ-5D [13‐15]. However, the LEIPAD scales give a more nuanced description of this domain in the very elderly owing to distinct assessments of anxiety and depression and to an appreciation at four levels of intensity not only of what the participants feel subjectively but also of the functional impact of these feelings on their lives, which is a key factor. Our results in this domain can be explained in part by the state of health and individual autonomy of the participants. The effects of health problems on depression and anxiety have been described in a younger age group [8]. We also observed that poor health, bereavement and the illness of a relative or friend are factors that negatively affect this domain of HRQoL in those aged 80 or over. Almost three quarters of our EP reported being satisfied with their current condition in comparison to their past life, feelings echoed in studies involving younger elderly participants [8, 38]. The fact that half of our respondents were nevertheless pessimistic about their future can be explained by the strategy of “realistic expectations”: the greater the gap between one’s current situation and what one anticipates, the greater the risk of disappointment. To narrow this gap, the very elderly tend to revise their expectations downwards [39].

The ‘Sexual Functioning’ scale had the poorest HRQoL scores in the present study. Almost 60% of the respondents in the group had the highest score in this domain. However, this score did not significantly change as their age increased. Some studies have been made in the general population of the sexuality of EP up to the age of 78 years [40, 41] but to our knowledge only a very few studies of HRQoL have included the dimension of sexuality in the very elderly [42]. The response rate for items related to sexuality in our study was high (greater than 95%). In study populations not older than 65 years, the rate is generally far lower. A response rate similar to ours was, however, obtained by Molzhan et al. [42], who reported only 8.7% missing data for items related to sexual activity. The correlations evidenced in our study are consistent with the following explanatory hypotheses, which can of course be combined and are not the only ones possible.

The female EP in our study declared a significantly less satisfactory HRQoL on the ‘Physical Function’, ‘Depression and Anxiety’ and ‘Sexual Functioning’ scales in multivariate analysis, which confirms and complements previous findings for these domains in populations that were generally less elderly or whose quality of life was assessed by generic questionnaires [10, 13, 15, 45‐49]. Our findings also showed that the female participants had specific problems related to ageing that could in part explain their less satisfactory HRQoL: they were older than the men, more often widowed and living alone, had a perceived modest income, were less likely to be driving and were suffering from significantly more health problems, as reported in previous studies [27, 31, 37], in particular diseases of the musculoskeletal system and connective tissue and mental and behavioural disorders [50, 51]. Our study refines the results presented by König, namely that female gender was associated with more problems in most of the EQ-5D dimensions [13]. In our previous study of EP aged 65 years and over [8], HRQoL did not differ significantly according to gender, apart from sexual activity, for which the women reported a less satisfactory HRQoL. It would appear, therefore, that differences between men and women in terms of HRQoL arise with advancing age, which is consistent with findings of the “Vie Quotidienne et Santé” (vqs) survey of 2014, which suggested that in participants aged 75 years or over the situation is unfavourable for women in terms of functional impairments and limitations [27, 30]. The female EP also have a lower quality of life for the 'Self-care' dimension and, in multivariate models, a greater risk compared to men of having a deteriorated quality of life in this dimension. This is consistent with the fact that the total life expectancy at 65 years is longer in women compared to men, but that some of these “extra” years are with restrictions of personal care activities [6, 33]. Measuring HRQoL can be useful for studying the impact of some health problems, in particular diseases of the musculoskeletal system and mental and behavioral disorders, but also the establishment of actions and their impact on HRQoL in the health fields (prevention, screening, diagnosis and assessment, medical and psychosocial interventions, rehabilitation), the physical environment (for example, spaces and buildings accessible and useable by people with impairments, adjustment and improvement of elderly people's home) and community and health services (for example, home care, support for informal care) [3, 5].

We identified which particular domains of HRQoL in the very elderly, other than those related to health, are negatively affected by life events. For example, an unsatisfactory environment had a negative effect on the ‘Social Functioning’ and ‘Life Satisfaction’ scales. Not being able to drive had a negative effect on the ‘Self-Care’, ‘Cognitive Functioning’ and ‘Social Functioning’ scales. Incomes perceived as modest and financial worries during the previous 12 months were associated with a negative effect on the ‘Life Satisfaction’ scale. These findings are in line with those reported for EP aged between 65 and 75 years in studies of QoL [52, 53] and HRQoL [8] and enrich those of a study based on the EQ-5D in EP aged 75 years and over [13]. These findings can be useful during policy initiatives to create better age-friendly environments, whether in the field of outdoor environments (for example, support for community interaction and personal independence, places for recreation, physical activity and other leisure activities) or the domain of the social participation (for example, supportive environments for social exchange in the community). These findings can also be useful during policy initiatives concerning the domain of transport and mobility (for example, public transport, on-demand services and other support to improve mobility) [3]. As findings differ from one country to another, it is interesting to have recent data gathered in France.

Longer life expectancy presents numerous challenges, notably preserving the highest levels of HRQoL as long as possible. In our study, EP living at home who were aged 80 years and over reported good HRQoL in most domains except that of ‘Sexual Functioning’. Their HRQoL became worse when their health deteriorated. The female EP declared a significantly less satisfactory HRQoL. An unsatisfactory environment, not being able to drive, perceived modest income and financial worries negatively affected HRQoL. Identifying factors in our study that are potential determinants of HRQoL would be of direct benefit for individuals and could lead to concrete actions in public policy concerning health services (particularly home care, medical and psychosocial interventions, rehabilitation), means of transport (particularly public transport and on-demand services), living environment (particularly home improvement, spaces and buildings accessible and useable by elderly people including with impairments) and financial resources. Such initiatives would help improve the HRQoL of EP living at home until very old age.