Self-reported health complaints and their prediction of overall and health-related quality of life among elderly people

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International Journal of Nursing Studies 42 (2005) 147–158

Self-reported health complaints and their prediction of overall and health-related quality of life among elderly people Gunilla Borglina,*, Ulf Jakobssona, Anna-Karin Edberga, Ingalill Rahm Hallberga,b a

b

Department of Nursing, Faculty of Medicine, Lund University, P.O. Box 157, SE-221 00 Lund, Sweden The Va˚rdal Institute. The Swedish Institute for Health Sciences, Lund University, P.O. Box 187, SE-221 00 Lund, Sweden Received 8 March 2004; received in revised form 26 May 2004; accepted 1 June 2004

Abstract Objective: To describe and compare self-reported health complaints, overall and health-related quality of life and to investigate how health complaints, age, gender, marital status, living and dwelling conditions and socio-economy predicted overall and health-related quality of life. Data and Method: A sample of 469 persons (aged 75–99) responded to a postal questionnaire. Multiple linear regression analysis was used to examine possible predictors. Result: Self-reported health complaints such as pain, fatigue and mobility impairment significantly predicted low overall and health-related quality life. Women had significantly lower overall and health-related quality of life than men, and a significantly higher degree of self-reported health complaints. The regression models had more similarities than differences, implying that the overall quality of life instrument were sensitive to physical influences only supposed to be detected by health-related quality of life instruments. Several of the health complaints predicting low quality of life are amenable for being relieved by nursing care. In the care of older people nurses need to assess for several health complaints simultaneously and be aware of their possible interaction when outlining interventions. Nurses are able to facilitate early detection of health complaints negatively affecting quality of life by implementing more pro-active preventive work as well as a higher degree of thorough and systematic assessments. It also seems important to consider that older woman’s and men’s needs for high quality of life may differ. r 2004 Elsevier Ltd. All rights reserved. Keywords: Quality of life; Health-related quality of life; Aged; Fatigue; Pain; Mobility impairment

1. Introduction and background Growing old denote a higher probability to suffer from health conditions and multiple health complaints (Winblad et al., 2001; Pivcavet and Hoyemans, 2002). Many of these health complaints are likely to be of relevance for nursing care. Additionally, in most cases the older (75–84) and oldest old (85+) live with one or *Corresponding author. Tel.: +46-46-222-1928; fax: +4646-222-1935. E-mail address: [email protected] (G. Borglin).

more disease that cannot be cured whilst relief from consequences may be possible by focusing on their health complaints and quality of life (QoL). An everyday life marked by different health complaints will most likely affect the older people’s QoL. Thus, one goal of nursing should be to promote health and to help maintain or improve the older people’s QoL. For care, the challenge is to limit the impact of common health complaints in everyday life by appropriate nursing assessments and interventions that assist older people’s in remaining independent in their own home and in the community.

0020-7489/$ - see front matter r 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijnurstu.2004.06.003

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Developing adequate nursing interventions for the older and the oldest old requires a comprehensive understanding of the most common health complaints and their impact on QoL. Such knowledge can for example be gained by systematic assessment of the older people’s perception of their health complaints and their QoL. Assessing QoL, as a nurse, may work in several directions. According to Raphael et al. (1997) QoL assessments are helpful in identifying persons at risk of poor health in the absence of diagnosed illness and an improved QoL have to be a desired outcome of nursing interventions. Others (Vernon et al., 2000) suggest that assessments of individuals in general can serve as a diagnostic process facilitating the development of suitable nursing interventions. However, systematic assessment and interventions need to be underpinned by knowledge about what may affect the older persons every day life negatively. In a review of district nursing the quality of the assessments made showed a wide variation, where seldom monitored and key-parts showed to be missing (Vernon et al., 2000). Additionally, in a review by Frich (2003) aiming to describe nursing interventions at home visits and their effect on older people with chronic conditions, it was found that performed nursing interventions are rarely described in detail. Those described consisted of multidimensional assessments followed by advices and recommendations aiming to support the person to take an active role in health-related issues (Frich, 2003). Despite these shortages (Vernon et al., 2000; Frich, 2003) assessments and interventions must still be looked upon as important tools for nurses in their work of providing good-quality care. Thorough and systematic assessments followed by interventions can be an important means for nurses to effectively pinpoint the care needs of older people and one way to help to save strained resources, making sure that they are allocated where they are most needed. 1.1. Health complaints Only a limited numbers of studies (Hellstro¨m and Hallberg, 2001; Jakobsson et al., 2004) were found investigating among other variables, various health complaints simultaneously and their prediction of QoL in older populations. Hellstro¨m and Hallberg (2001) investigated older people’s (range 75–99 years) and showed that depressed mood, loneliness, fatigue, sleeping problems and the number of reported diseases were significantly associated with low QoL. Jakobsson and colleagues (2004) demonstrated that among older people’s (85+) in pain functional limitations, fatigue, sleeping problems and depressed mood, were associated with low QoL. Additionally, these studies demonstrated that a high prevalence of different health complaints is common among the older and oldest old and that there is a high possibility of several health complaints being

present simultaneously. Thus, implying a complex relationship between the actual number of health complaints, their nature and their prediction of QoL. Consequently this stresses the importance of not being too narrow when investigating factors that may affect and/or predict the older people’s perception of health and QoL. Studies investigating a single health complaint and its prediction of older (65+) people’s QoL are common. These studies showed that depression (Burggraf and Barry, 1996), sleeping problems (Grimby and Wiklund, 1994) and pain (Dening et al., 1998; Ross and Crook, 1998; Jakobsson et al., 2003) had a negative impact on older people’s QoL. Other studies indicated that older women in general reported lower QoL than older men did (Kendig et al., 2000; Lim and Fisher, 1999). The greater part of studies presented here have more or less investigated the youngest of the older people (65–85 years) and often, in contrary to the design in this study, excluded those living in special accommodations, perhaps giving a more positive view of older people’s health and QoL. It is necessary to include also the oldest old, regardless of living conditions, to understand how various health complaints predict older people’s QoL. This may facilitate the knowledge base for nursing care and for developing interventions striving to minimise the effect of common health complaints affecting older people’s everyday life and their QoL. 1.2. Quality of life Few studies seem to have used QoL and health-related quality of life (HRQoL) measures simultaneously in older people, although it may be that these measures complement each other rather than reflect the same phenomenon. According to Frytak (2000) a challenge for researchers and health care providers is: ‘‘to avoid measures of QoL/HRQoL that exclude or ineffectively explore areas that are important to an older population or worse yet are used in a manner that disadvantages older adults in health resource allocation decisions’’ (p. 200). There is a need to delineate the domains of QoL that have meaning to older adults (Frytak, 2000). This stresses the importance of viewing QoL as a multidimensional concept and not as related to health only. Overall QoL is often depicted as an elusive multidimensional phenomenon. Browne et al. (1994) described QoL as ‘‘a dynamic interaction between the external conditions of an individual’s life and the internal perception of those conditions’’ (p. 235). This is not quite the same as HRQoL, which is most commonly used in health care contexts. The theoretical framework of HRQoL is largely based on a multidimensional perspective of health as physical, psychological and social functioning and well-being. This is in line with WHO’s definition of health: a state of complete

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physical, mental and social well-being and not merely the absence of disease or infirmity (Bowling, 1998; O’Boyle, 1997). Achat et al. (1998) described the basic components of HRQoL as functional status, well-being and general health, and suggested that these components are prerequisites for a person to meet the day-to-day demands of life and thereby fulfil needs and desires. This description of HRQoL fits the Short Form Health survey SF-12 (SF-12) aiming to measure functioning, well-being and general health status (Ware, 2000). Overall QoL, in contrast, takes a broader view than HRQoL. There are several instruments developed to measure QoL, mostly for use in younger populations. However, the Life quality Gerontological Centre scale (LGC scale) was especially developed for measuring QoL among older people (Jadba¨ck et al., 1993) and it was developed by means of factor-analysing items compounded from already established questionnaires. One of the questionnaires was the Life Satisfaction Index A (LSIA) developed by Neugarten et al. (1961). Neugarten et al. (1961) assumption for developing LSIA was based on the inappropriateness of measuring psychological well-being in old age by middle-age standards, e.g. activity or social involvement, and on the conviction that the individual is the only proper judge of present and past life satisfaction. Altogether, from a nursing care perspective it is important to gain knowledge of how common it is that the older, especially the oldest old, have different health complaints, type of health complaints and how they relate to QoL and HRQoL. Such knowledge can contribute to more effective and direct nursing assessments and interventions. 1.3. Aim The aim was to describe and to compare health complaints, overall and health-related quality of life among older people aged 75 years and above. The aim was also to investigate how self-reported health complaints, age, gender, living and dwelling conditions, marital status, and socio-economy predicted older people’s overall and health-related quality of life.

2. Method 2.1. Sample The sample of this study was 469 people aged 75–99 years, living in ordinary homes or in special accommodation. A self-administered postal questionnaire was sent out to an age-stratified randomised sample (n=1 000). Two reminders were sent, and the last letter once again included the postal questionnaire. Each age group, 75–79, 80–84, 85–89 and 90–99 years had 250 persons.

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The sample consisted of more women (67.1%) than men (32.9%) as it aimed to reflect the actual gender distribution in these age groups. The response rate among the age groups was 75–79=61%, 80–84=53%, 85–89=43%, 90–99=38%. Three questionnaires were answered by another person in the household, and were therefore excluded. Explanations for not participating (n=80) were being too sick, having a cognitive disease, being too old or just not wanting to be a part of the study. Thirty-nine persons were missing (28 deceased, 11 addresses unknown) and 2 persons were excluded as they lived outside the county. The Ethics Committee of the Medical Faculty at Lund University approved the study (LU 478-99). 2.2. Settings The data collection was performed among subjects living in a southern region of Sweden were the population is divided among municipalities varying from countryside to larger towns. The labour market consists of farming, industry and a large public sector related to education and health care. The total number of residents in this region corresponds to 12.6% of the Swedish population and the age distribution is similar to that in the rest of the country, with 9% above 75 years and 18% of the population over 65 years (Statistics Sweden, 2000). 2.3. Postal questionnaire The questionnaire included questions about QoL and HRQoL as well as common health complaints (Fig. 1) previously used in other studies (Hellstro¨m and Hallberg, 2001). Health complaints were measured with one overarching question, ‘‘Have you been troubled by one or more of the following complaints in the last three months.’’ Each health complaint had four response alternatives: ‘‘no, not at all’’, ‘‘yes, a little’’, ‘‘yes, rather much’’ and ‘‘yes, very much.’’ The questionnaire also included variables about economy (‘‘How well does your economy cover your needs?’’), with five response alternatives ranging from ‘‘very well’’, to ‘‘very badly’’, and variables for age, gender, marital status, living and dwelling conditions (Table 1). Marital status included married, widow/er, single and divorced. Dwelling conditions included flat, house, special accommodation e.g. nursing home, sheltered accommodation and group dwelling whilst living conditions included countryside, hamlet, village and city. The SF-12 (Ware et al., 1996) is a shorter version of the previously developed SF-36 and validated for Swedish conditions (Sullivan et al., 1997). It measures HRQoL with twelve items in eight areas in one physical component summary score (PCS) and in one mental component summary score (MCS). The PCS consists of

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Vomiting Fever Intractable wounds Diarrhoea Nausea Faecal incontinence Breathlessness during rest Skin rash/eczema Dyspnoea Appetite loss Cough Complaints from the genitalia Complaints from the urinary tracts Chest pain Palpitation Headache Disturbances of speech Cold Depressed Anxiety Obstipation Swollen legs Abdominal pain Vision impairment Nervous/Worried Mobility impairment Fatigue Breathlessness during activities Urinary incontinence Dizziness Sleep problems Walking impairment Pain Hearing impairment Memory decline 0%

10%

20%

30%

40%

Very much

50% Rather much

60% Little

70%

80%

90%

100%

No

Fig. 1. None age-weighted prevalence in percentage of severity of self-reported health complaints.

the areas: physical functioning, role physical, bodily pain and general health, while the MCS areas are: vitality, social functioning, role emotional and mental health. Scores are standardised to range from zero poorest well-being to 100 highest well-being (Ware et al., 1996). The LGC scale is an overall quality of life instrument (Jadba¨ck et al., 1993) consisting of 49 items developed through factor analysis of previously used items, aiming to measure life satisfaction (Neugarten et al., 1961; Lawton, 1975; Rubenowitz, 1980), which gave a 10-factor

solution. Two factors denominated, present quality of life (11 items) and life span quality (4 items) were used for this study. Ten of the items in the two factors originate from LSIA and aim to measure (a) Zest vs. apathy, (b) Resolution and fortitude, (c) Congruence between desire and achieved goals, (d) Positive self-concept, (e) Mood tone. The constructors (Jadba¨ck et al., 1993) of the scale developed four of the remaining items (‘‘As a whole, how do you judge that your life has been from childhood until now?’’ ‘‘How do you consider your life in general at the moment?’’ ‘‘How do you experience your present health

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Table 1 Characteristics of the respondents (n=469) and comparison for gender

a

Age mean (SD) Marital status (%)b Married Widow/er Unmarried Divorced Single Dwelling condition (%)b Ordinary dwelling Special accommodation Living conditionsb City Countryside and hamlet Village Economic situation (%)b Good Bad Health-related Quality of Life: SF-12 PCS Mean (SD)a Health-related Quality of Life: SF-12 MCS Mean (SD)a Overall Quality of Life: LGC Life span Mean (SD)a Overall Quality of Life: LGC Present life Mean (SD)a a b

Females (n=290)

Males (n=179)

p-value

83.9 (5.7)

82.2 (5.6)

o0.002 o0.001

22.4 61.9 6.3 4.2 5.2

69.5 21.5 2.8 2.8 3.4

82.4 17.2

91.6 8.4

47.3 34.8 17.9

44.7 35.8 19.6

83.4 16.6 37.7 (12.0) 51.0 (11.2) 0.86 (0.21) 0.52 (0.23)

93.3 6.7 40.6 (11.9) 54.2 (8.8) 0.89 (0.17) 0.60 (0.24)

o0.07 o0.840

o0.002

o0.03 o0.005 o0.08 o0.006

Student’s t-test. Chi-squared test.

status?’’ ‘‘Do you usually feel low-spirited because every day is the same?’’). The fifth item (‘‘Do you feel that people in general appreciate the things you do and accomplish?’’) was taken from Rubenowitz’s (1980) life quality scale. Scores for the LGC scale are calculated as a standardised mean value for each factor, where zero is the worst possible value and 1 is the ideal value, or as a total mean score for all ten factors. 2.4. Data analysis Student’s t-test, Chi-squared and Mann–Whitney Utest were used to identify differences between women and men. Multiple linear regression analyses (stepwise) were conducted with QoL (Present QoL, Life span QoL) and HRQoL (PCS, MCS) as dependent variables, controlling for age, gender and socio-economy (cf. Altman, 1997). Independent variables were health complaints with prevalence above 40%. This cut-off point was selected to ensure that the most common health complaints were included. Additional concerns were to reduce the models and thereby eliminate the collinearity risk caused by the combinations of independent variables (Polit, 1996). Among those participating in this study the oldest old age group (90+) proved to be over-represented (18.6% vs. 8.4%) whilst the old age group (75–79 years) proved to be under-represented (32% vs. 43.7%) compared to

their number in the general population. Accordingly the health complaints were weighted for age against the age strata N in the general population before deciding which health complaints to include in the analyses. Spearman’s rank-order correlation was additionally conducted between the dependent variables and between the 35 health complaints to avoid entering variables highly correlated with each other (e.g. collinearity problems). Walking impairment and mobility impairment were highly correlated (r=0.71). Since the question about mobility problems covered a wider range of functional limitations than the question about walking impairment, mobility problems replaced walking impairment. The health complaints (Fig. 1) and marital status was coded as dichotomous ‘‘dummy’’ variables (Altman, 1997). All health complaints had ‘‘no, not at all’’ as reference and marital status had married as reference. The variable living conditions were dichotomised as either ordinary dwelling (flat, house) or special accommodation (nursing home, sheltered accommodation, group dwelling). Socio-economic variables were dichotomised to good as reference (e.g. ‘‘very good’’, ‘‘good’’, ‘‘neither good nor bad’’ =1) and bad (e.g. ‘‘bad’’, ‘‘very bad’’ =0). Living conditions were dichotomised to countryside (‘‘countryside’’ and ‘‘hamlet’’), village or city, with city as the reference. Tests for possible collinearity (tolerance and VF) were performed and the Kolmogorov–Smirnov test was used to test residuals

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for normality. This showed that the residual for the three models did not differ significantly from the normal distribution, except for the regression analysis with life span quality (po0.001) as dependent variable. Due to this and to a low adjusted R2 (0.168) this regression model was dismissed. Reliability was tested with Cronbach’s alpha (Cronbach, 1951), the internal consistency were 0.85 for physical HRQoL (PCS) and 0.82 for mental HRQoL (MCS) in SF-12 whilst internal consistency for the LGC’s present quality of life items was 0.85 and 0.70 for the life span quality items. Data were computerised and analysed using SPSS 11.01 for Windows (Norusis, 1992).

3. Results Mean age (range 75–99 years) for the sample n=469 was 83.2 (SD 5.7) and the women were significantly older (po0.002) than the men. The number of women (68.1%) and men (38.2%) participating was in accordance with the initial sample distribution between the sexes (women 67.1%, men 32.9%). In the sample 21.5% of the men were widowers, whilst 61.9% of the women were widows (po0.001). Among the women 17.2% lived in special accommodation, compared to 8.4% of the men (po0.07). Women experienced a significantly (po0.002) worse economic situation than men as more women than men reported a poor economic situation. No differences were found when comparing men and women’s living conditions (Table 1). In the sample, 54.7% (50.3%) of the respondents reported some degree of hearing impairment. The percentages shown in brackets are the age-strata weighted frequencies. Also 71% (70.3%) of the respondents reported some degree of memory decline, 45.3% (42.4%) dizziness, 45.2% (42.5%) urinary incontinence, 57.2% (55%) pain, 42.5% (38.7%) mobility impairment, 44.7% (43.5%) breathlessness during activities, 44.7% (42.5%) fatigue, 50.1% (51.9%) sleeping problems, and 40.3% (41.9%) of the respondents reported some degree of being nervous/worried (Fig. 1). Women reported significantly more memory decline, dizziness, urinary incontinence, pain, mobility impairment, breathlessness during activities, fatigue, sleep problems and being more nervous/worried than men (Table 2). The linear regression analyses (Table 3) revealed that pain was significantly associated with low present QoL as well as with low physical and mental HRQoL (PCS and MCS). Mobility impairment was associated with low physical HRQoL and low present QoL. Fatigue, being nervous/worried and sleeping problems were associated with both low mental HRQoL and low present QoL whilst being a widow/er was associated with low present QoL. Urinary incontinence was negatively related to physical and mental HRQoL whilst

breathlessness during activities was associated with low physical HRQoL. The three multiple linear models had acceptable R2 values ranging from 41% to 57% (Table 3). Women had significantly lower overall QoL and HRQoL than men, except for life span quality (Table 1). Women’s overall mean score of physical HRQoL (SF-12) was 37.7 (SD 12.0) this can be compared to the norm value 39.2 (11.2) for women (75+) in the general Swedish population. Women’s overall mean score of mental HRQoL (SF-12) was 51.0 (SD 11.2) compared to the norm value 48.4 (SD 12.0) (Sullivan et al., 1997). HRQoL in the total sample was 38.9 with a standard deviation 12.0 for physical HRQoL (norm 75+, 40.3, SD 11.6) and 52.3 (SD 10.4) for mental HRQoL (norm 75+, 51.5, SD 11.0) (Sullivan et al., 1997). In the total sample 48% had physical HRQoL scores at the norm value or above the norm whilst 60% of the total sample had mental HRQoL scores at the norm value or above. QoL in the total sample was 0.55 (SD 0.24) for present QoL, with men alone having significantly higher present quality of life, 0.60 (SD 0.24) than women, 0.52 (SD 0.23). This is comparable with a study by Hagberg et al. (2002) demonstrating an overall mean for present QoL at 0.74 (SD 0.15). Life span quality in the total sample was 0.87 (SD 0.19), which can be compared with an overall mean of 0.91 (SD 0.13) for life span QoL found in the same study (Hagberg et al., 2002). In this study 53% of the total sample had a mean score for present QoL at or above the overall mean whilst 57% of the sample had a mean score for life span QoL at or above the overall mean.

4. Discussion Several health complaints reported by the older persons showed to significantly predict low QoL as well as HRQoL. Indicating that to promote QoL and HRQoL when caring for older people nurses need to adopt a comprehensive approach and include several factors simultaneously to outline effective interventions. Pain was the only health complaint predicting low QoL and HRQoL in all of the three regression models. Low physical HRQoL were predicted by health complaints such as mobility impairment, urinary incontinence and breathlessness during activities whilst low mental HRQoL were predicted by fatigue, being nervous/ worried, sleeping problems and urinary incontinence. Furthermore mobility impairment, fatigue, being nervous/ worried, sleeping problems and being a widow/er showed to predict low QoL. Women had significantly lower QoL and HRQoL and reported a higher degree of health complaints than men did. Additionally, women were significantly older, had a worse economic situation and were more often widows and lived to a larger extent

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Table 2 None age-weighted prevalence of self-reported health complaints and comparison for gender Female

Male

47.5 30.4 14.0 8.2

41.8 35.2 19.4 3.6

Hearing impairment (%) None Little Rather Very Memory decline (%)a None Little Rather Very much Dizziness (%)a None Little Rather much Very much Urinary incontinence (%)a None Little Rather Very much Pain (%)a None Little Rather much Very much Mobility impairment (%)a None Little Rather many Very much Breathlessness during activities (%)a None Little Rather much Very much Fatigue (%)a None Little Rather much Very much Sleep problems (%)a None Little Rather many Very much Being nervous/worried (%)a None Little Rather much Very much

26.3 56.0 10.4 7.3

33.3 53.9 10.3 2.4

50.6 38.9 7.4 3.1

61.1 28.1 7.2 3.6

50.4 29.6 10.0 10.0

62.2 27.6 5.1 5.1

42.5 26.8 15.4 15.4

43.2 24.1 19.8 13.0

54.6 22.7 8.8 13.8

62.2 21.3 9.8 6.7

53.9 34.4 6.6 5.1

57.4 30.9 9.3 2.5

51.6 27.7 13.3 7.4

61.1 24.1 11.1 3.7

39.7 35.9 16.0 8.4

61.6 25.6 9.8 3.0

50.2 34.9 11.1 3.8

71.1 22.0 3.8 3.1

a

p-value o0.438

a

o0.05

o0.07

o0.007

o0.9

o0.07

o0.5

o0.04

o0.001

o0.001

Mann–Whitney U-test.

in special accommodation (p=0.07) than men. It was noteworthy that the regression models had more similarities than differences indicating that the LGC

scale is sensitive to physical influences, which otherwise are supposed to influence only HRQoL measured for instance by SF-12.

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Table 3 Variables predicting PCS/MCS (SF-12) and Present QoL (LGC) in total sample Dependent variable

Final model independent variables

Health-related QoL SF-12 PCS (n=284)

Urinary incontinence—a little Breathlessness during activities—a little Breathlessness during activities—very much Pain—a little Pain—rather much Pain—very much Mobility impairment—a little Mobility impairment—rather much Mobility impairment—very much Pain—very much Urinary incontinence—a little Urinary incontinence—rather much Nervous/worried—rather much Nervous/worried—very much Fatigue—a little Fatigue—very much Sleep problems—rather much Sleep problems—very much Being a widow/widower Pain—very much Mobility impairment—a little Mobility impairment—very much Nervous/worried—rather much Nervous/worried—very much Fatigue—a little Fatigue—rather much Fatigue—very much Sleep problems—rather much

Health-related QoL SF-12 MCS (n=284)

Overall QoL LGC PQoL (n=279)

Adjusted R2

B 2.424 2.417 8.023 4.058 8.781 15.130 6.826 8.544 9.404 6.117 2.706 6.239 9.187 10.293 2.732 10.527 4.274 5.156 0.066 0.098 0.085 0.109 0.151 0.151 0.087 0.154 0.200 0.109

0.567

0.457

0.414

95% CI for regression coefficient 4.567 to 4.470 to 14.730 to 6.369 to 11.606 to 18.414 to 9.250 to 12.265 to 13.499 to 8.969 to 4.762 to 9.882 to 13.017 to 15.669 to 4.798 to 15.211 to 7.237 to 8.973 to 0.118 to 0.163 to 0.142 to 0.202 to 0.239 to 0.270 to 0.140 to 0.228 to 0.311 to 0.177 to

0.281 0.364 1.316 1.748 5.957 11.846 4.401 4.822 5.309 3.265 0.651 2.596 5.357 4.916 0.666 6.233 1.310 1.340 0.014 0.033 0.028 0.017 0.064 0.032 0.034 0.081 0.089 0.042

p-value o0.027 o0.021 o0.019 o0.001 o0.001 o0.001 o0.001 o0.001 o0.001 o0.001 o0.010 o0.001 o0.001 o0.001 o0.010 o0.001 o0.005 o0.008 o0.013 o0.003 o0.004 o0.020 o0.001 o0.013 o0.001 o0.001 o0.001 o0.002

Variables entered in the regression analysis: Marital status, dwelling conditions, living conditions, hearing impairment, declined memory, dizziness, urinary incontinence, pain, mobility problems, breathlessness during activities, fatigue, sleeping problems and nervous/worried. Age, gender, socio-economy was held constant during all of the analysis.

4.1. Limitations and strengths There are threats to internal as well as external validity in this study, of which a low response rate is the largest. Those not participating (non-responders and missing) were found to be older (po0.001) with a mean age of 86.5 (SD 5.8) and more often women (po0.001). Reasons reported for not participating were being too sick, being too old or having a cognitive disease. Although 40% of the sample consisted of the oldest old (85+), this study most likely failed to include the frailest of them. Studies (Hayes et al., 1995; Andresen et al., 1999) with older people have shown low response rates, especially when the oldest old and those living in nursing homes are included. Thus, the results of this study have to be interpreted with caution and perhaps at best reflecting those with better QoL and HRQoL than the older population in general. Another threat to validity is the cross-sectional study design, which does not allow for effects of ageing being

distinguished from cohort effects (Idler, 1993). A problem with the design is ‘‘natural selection effects’’ or the extent to which the participants represent the heterogeneity of their respective populations’ subgroups and therefore also represent an alternative explanation for observed gender differences (Smith and Baltes, 1998). As the sample reflected the gender distribution in the county, the risk of a large distortion regarding age or a gender imbalance may have been minimised (cf. Smith and Baltes, 1998). The procedure of age-weighting the health complaints resulted in minor adjustments of the number of self-reported health complaints, implying that the sample represented the general population fairly well, in spite of the distortion between the numbers of old and oldest old participating. Additionally, as the sample were randomly selected, representing rural and industrial areas it may be possible to generalise these result to fairly healthy older people. Using an instrument (LGC) not yet fully psychometrically evaluated may also be a threat to the validity of

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the results. The LGC scale, however, was included to apply a broader perspective on QoL than HRQoL only. This proved to be useful, as being a widow/er and its prediction of low present QoL would not have been detected if only SF-12 had been used. The items in SF-12 are more physically focused, with questions about ill health and disability, whilst LGC items are more emotionally focused. This finding supports Frytak’s notion (2000) about the importance of avoiding measures of QoL and HRQoL that exclude or ineffectively explore important areas for the older population. The use of two different QoL instrument strengthened the results and served as a validation of the instruments since more or less the same health complaints i.e. pain, fatigue, mobility impairment, nervous/ worried, sleep problems, urinary incontinence and breathlessness during activities, as well as being a widow/er predicted low QoL and HRQoL regardless of instrument used. Notable was that the LGC scale proved to be sensitive to mental, physical and social components, indicating that it could be useful in samples of older people. 4.2. Findings The findings of this study indicate that several common health complaints may occur simultaneously and that they negatively affect older people’s QoL and HRQoL (Table 3). It is not possible to determine causality or the relationship between the different health complaints, other factors and QoL and HRQoL, but it is likely that different health complaints interact with each other rather than work in isolation (Hellstro¨m and Hallberg, 2001; Jakobsson et al., 2004). It may well be that being struck by several health complaints simultaneously interacts with a higher risk of dependency. However, some of the health complaints—pain, fatigue and mobility impairment—proved to be more prevalent and more prominent than others in terms of significantly predicting a low QoL and HRQoL. From a clinical perspective, systematic nursing assessment of these specific health complaints is therefore of great importance in order to facilitate early detection and interventions. Additionally, nursing needs to consider targeting several health complaints simultaneously to effectively promote the older person’s ability to keep on managing an independent life while maintaining or improving QoL and HRQoL. Pain needs special attention in the care of older people as it predicted low present QoL and low physical and mental HRQoL. It is known that pain is common among older people and that it has a negative affect on their QoL and HRQoL (Dening et al., 1998; Ross and Crook, 1998). In this study every second respondent reported pain to some degree and 36% of those reported ‘‘rather or very much’’ pain. It is not possible to tell

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from this study if the respondents used pharmacological pain-relieve and/or alternative pain management methods or if eventual pain-relieve is inadequate. Jakobsson and colleagues (2003) compared older people with and without pain and their QoL and found a complex relationship between pain and other health complaints such as functional limitations and sleeping problems. This further indicates that experiencing pain together with other health complaints such as fatigue and mobility impairment can seriously aggravate the older person’s ability to remain independent of others. It may denote a viscous circle, where the older person avoids movements and activities to eliminate pain, leading to increased pain and further mobility impairment. Thus, the findings of this study stresses the importance of implementing systematic nursing assessment for pain and for ensuring sufficient pain relief either pharmacological and/or alternative interventions such as rest, distraction or support groups to promote older people’s QoL and HRQoL. Also fatigue is a health complaint that needs special attention since in this study as many as 45% reported fatigue to some degree and 18% reported ‘‘rather or very much’’ fatigue. With regard to the high prevalence of fatigue in this study and in other studies focusing on older people (Hellstro¨m and Hallberg, 2001; Liao and Ferrell, 2000; Tiesinga et al., 2002), it is notable that only a few studies concerning fatigue vs. QoL and HRQoL in older populations (85+) were found. Thus, implying that fatigue may not yet be sufficiently recognised in nursing as a health problem to look out for among older people. Fatigue additionally had a negative effect on mental HRQoL as well as on present QoL. Hellstro¨m and Hallberg (2001) found resembling results, with 55% of the respondents (>75 years, n=448) reporting some degree of fatigue, and fatigue was associated with low QoL. It is difficult to establish whether fatigue is a cause, effect or indication of something else. Winningham et al. (1994) suggested that fatigue could have a unique relationship to other symptoms, as it is a primary symptom and affects the person’s activity. This may lead to a secondary increased fatigue and further decreased functional ability (Winningham et al., 1994). Older people suffering from fatigue may have to face deficient strength to carry out activities of daily living and a downward trend in QoL and HRQoL. The result of this study implies that fatigue needs to be recognised as an equally serious health complaint as pain in the care of older people, therefore a heightened awareness of the need to systematically assess and intervene against fatigue seems urgent. In this study, some degree of mobility impairment was reported among as many as 42.5% of the respondents and it was significantly associated with both low physical HRQoL and present QoL. There is a high

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probability that the older people also report some degree of pain and also fatigue simultaneously with reporting mobility impairment (Table 3) and these complaints may add to each other in terms of decreased QoL and HRQoL. Mobility impairment has previously been shown to be associated with other health problems, such as urinary incontinence, fatigue and pain (Ostir et al., 1999; Grimby and Svanborg, 1997). Accordingly, interventions targeting several health complaints at the same time seem important in nursing care. There were no significant differences between men and women in reporting mobility impairment. However, other studies (Leveille et al., 2000) have shown that the prevalence of mobility impairment in general is higher among women than among men. It might be that the women in this study were healthier than in general and therefore no gender differences were discernible in mobility impairment. For older people mobility impairment can cause loss of autonomy as well as feelings of dependency. This means that nursing care aiming to prevent and/or rehabilitate mobility impairment is important to make it easier for older people to remain as active as possible. Interventions such as preventive home visits conducted by nurses have been shown to have a positive effect on older people’s functional ability (Stuck et al., 2000; Van Haastregt et al., 2000). Thus, nursing interventions such as preventive home visits consisting of support and health advice may have a positive effect on mobility problems by postponing functional decline among older people. Women appeared to be more vulnerable for low QoL and HRQoL than men were. This may be explained by several factors such as that women were older, more often widows and reported a higher degree of health complaints than men did. Being a widow was also significantly associated with low present QoL. Women have previously been found to report lower QoL and HRQoL than men (Lim and Fisher, 1999; Sullivan and Karlsson, 1998; Sprangers et al., 2000). It may be that women’s longevity entails greater disability and multimorbidity, which implies a longer period of frailty, incapacity and dependency (Smith and Baltes, 1998) than for men. With this cross-sectional study, however, it is not possible to establish whether the women’s poorer health, worse-off economic situation, their widowhood and higher age determined their lower QoL and HRQoL, or if it was gender per se that did so. However, the higher incidence of several different health complaints and the lower QoL and HRQoL among the older woman than among the men may well have substantial clinical implications. Therefore, since women report a great deal more health complaints as well as different health complaints than men do, this needs to be taken into account when nurses assess and intervene among women as their needs for optimal QoL and HRQoL may differ from those of men.

5. Conclusion and clinical implications Several health complaints of importance were found that could form an important basis for knowledge to promote health and to prevent low QoL and/or HRQoL among older people. The findings indicate that nurses in the care of older people need to be aware of that several health complaints may be present at the same time and that some of these health complaints also are more prevalent than others. Pain, fatigue and mobility impairment had a significant association with low QoL as well as with low HRQoL for older people. Additionally, women seemed to be more vulnerable to low QoL and HRQoL than men, probably explained by higher age and more complaints as well as a poorer economic situation. The prevalence of pain, fatigue and mobility impairment as well as their impact on QoL and HRQoL of the frailest and oldest old might be even higher since this study did not succeed in fully including them. Several of the health complaints predicting low QoL and HRQoL found in this study are amenable for being assessed by nurses as well as by being relieved by nursing interventions. All in all the findings of this study may underpin that nurses need to strive towards systematic assessments of different prevalent health complaints simultaneously as well as towards preventive interventions among older people living in the community. This is supported by that in several European countries resent directions within national health policies is to work towards preventive home visitation programs (Stuck et al., 2002). Preventive home visiting programmes make it possible to look out for early symptoms, such as health complaints signalling the onset of more serious conditions and to start interventions and treatment early. Even if conflicting results exist from evaluations of preventive home visiting programmes, the results from some studies (Stuck et al., 2000; van Haastregt et al., 2000) indicate that such interventions postpone functional decline as well as hospitalisation and nursing home admission. It might be fair to assume that among most old people, remaining in one’s own home is preferable and most likely has a positive impact on their perception of autonomy and quality of life. Therefore, preventive visiting work would facilitate nurses in their work of supporting and enhancing older people’s health and their QoL and HRQoL.

Acknowledgements We wish to acknowledge the help and support of our colleagues, Magdalena Andersson, Anna Ekwall, Ylva Hellstro¨m, Ann-Christin Janlo¨v, Karin Stenzelius and Bibbi Thome´. We are also most grateful to Per-Erik Isberg for his assistance in the statistical analysis, to

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Alan Crozier for revising the language and to Ewa Olson the librarian for her swift work with references. Last but not least, thanks to all the respondents who helped us by answering the postal questionnaire. The study was supported by grants from the Swedish Nurses’ Association, Grant number 2000 026 from the Va˚rdal Foundation, the Uppsala Hemsysterskola Foundation, Greta and Johan Koch’s foundation and the Department of Nursing, Faculty of Medicine, Lund University.

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