Like many countries around the world, Australia has an ageing population. By 2050, 22.7 per cent of the Australian population will be aged 65 years and over compared to 13.5 per cent in 2010 (Commonwealth of Australia Attorney General’s Department, 2010). Over that period the number of people aged 85 years and over will quadruple from current levels and will then represent 5.1 per cent of the Australian population. While the impending economic ‘burden’ of ageing populations has pre-occupied governments, there is increasing recognition that society needs to be concerned with maximising quality of life (QOL) for people as they age as a basic human right and also as a means of reducing the burden (Kendig & Browning, 2012; Australian Human Rights Commission, 2012).
While increasing longevity is a cause for celebration globally, the World Health Organization (WHO) has called for ‘adding life to years’, which is explicit recognition of the importance of QOL in addition to longevity for older people (WHO, 2012). Policy approaches that promote healthy ageing reflect the desire to support older people to remain active, valued and engaged citizens for as long as possible and, during the last years of their life, to live a comfortable, meaningful life, and such approaches are now strongly advocated globally (European Commission, 2013; WHO, 2002).
To examine quality of life in older people we need to recognise the considerable heterogeneity of physical and psychological functioning across the large age range of people over 65 years. Whilst on average physical functioning declines with age as chronic illnesses and disability increase, there is large individual variation in health and wellbeing outcomes and in the experience of ageing. Although biomedical risk factors can drive this variation, behavioural and psychosocial factors are key determinants and indicators of QOL in old age (Abeles, Gift, & Ory, 1994). In addition, these influences arise from both life course experiences as well as current circumstances (Mollenkopf & Walker, 2007). Finally, in examining QOL in older people we need to keep in mind the WHO’s pivotal definition of health: “Health is a state of complex physical, mental and social well-being and not merely the absence of disease or infirmity” (WHO, 1952, p.100).
What is quality of life in old age?
Research and commentary in this area has been driven by various theoretical and disciplinary perspectives (Mollenkopf & Walker, 2007). The QOL literature in the field of ageing also overlaps with concepts such as successful, active and healthy ageing. Broadly, psychological perspectives have focused on psychological wellbeing as a marker of successful ageing. QOL domains such as social connectedness, mastery and autonomy are included in these approaches (see for example Diener, Suh, Lucas, & Smith, 1999; Ryff, 1989). The psychologist M. Powell Lawton proposed a multidimensional model of quality of life in old age in 1991 that incorporated various competencies, including behavioural and social competence and psychological wellbeing, as well as the role of the environment in supporting QOL. Lawton also emphasised the importance of temporal dimensions in QOL. In evaluating their QOL, older people may examine and reflect on their past, present and future circumstances and experiences.
Later work by Bowling and her colleagues has emphasised the need to examine lay or consumer perceptions of the meaning of QOL, not just technical and theoretically derived dimensions that may reflect the focus of clinicians rather than their clients. She found that the key QOL themes or dimensions nominated by community-dwelling older people included “… psychological well being and positive outlook, having health and functioning, social relationships, leisure activities, neighbourhood resources, adequate financial circumstances and independence” (Bowling et al., 2013). However, consistent with Lawton’s view, namely that circumstances and environment influence personal meanings of QOL, it has been found that older consumers’ views of the key dimensions may vary across community and aged care settings.
For older residents in aged care settings, highly rated QOL domains often include physical comfort, functional competence, privacy, autonomy, dignity, meaningful activity, meaningful relationships and safety (see for example Kane, Kling, Bershdsky, et al., 2003). Again the importance of the older person’s perspectives in defining QOL has been highlighted in the literature and these perspectives may vary according to health status, gender, ethnicity and socio-demographic background. Older people with cognitive impairment may face particular challenges in evaluating and expressing their QOL. However, some studies have demonstrated that it is possible and appropriate to measure QOL in older people with cognitive impairment (Abramson, Clark, Perkins, & Arling, 2012).
Thus, QOL in old age is a multidimensional construct that is useful in evaluating ‘adding life to years’. It is important to use domains of QOL that are meaningful to older people themselves, and to recognise that these domains will vary according to the person’s life circumstances and personal and social characteristics.
What influences quality of life in old age?
The main threats to a high QOL in older people are chronic physical and/or psychological illness. Chronic illness affects older people disproportionately and is a major burden for older people and their carers and families. However, many argue that it does not need to be this way. In 2011 the US National Center for Chronic Disease Prevention and Health Promotion stated:
Research has shown that poor health is not an inevitable consequence of aging. Effective public health strategies currently exist to help older adults remain independent longer, improve their quality of life, and potentially delay the need for long term care (p.2).
While chronic illnesses often drive the quality of life in older people, behavioural, psychological, social, environmental and economic resources can moderate their impact. For example, health promoting behaviours can assist with the management of chronic illnesses (Browning, Heine, & Thomas, 2012), and personal control over one’s life activities and environment can influence perceptions of wellbeing in the face of illness (Mollenkopf & Walker, 2007). Social resources, including social activities and social support, are key influences on QOL particularly in impoverished environments such as low SES neighbourhoods (Mollenkopf & Walker, 2007). Positive self-perceptions of ageing are important influences on wellbeing (Levy, Slade, & Kasl, 2002). Neighbourhood characteristics, including social cohesion within a neighbourhood and safety, are also associated with wellbeing in late life (Pearson, Windsor, Crisp, et al., 2012). Economic resources are important in providing a living standard that allows the older person to live an independent and socially connected life and to access appropriate health care.
| ENHANCING QUALITY OF LIFE FOR OLDER PEOPLE |
- Deliver what older people want rather than what we think they want
- Understand that there are individual differences in older people’s wishes that need to be incorporated into service tailoring
- Explicitly include QOL measurement and concepts in service evaluation and quality improvement
- Help older people avoid and manage chronic illness
- Promote meaningful social engagement
- Improve self perceptions of ageing by valuing and promoting the contributions that older people make to society
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How can services maximise quality of life in old age?
Australia has been slow to act practically and systematically in promoting healthy ageing and maximising QOL amongst its older citizens. Most ageing policy in Australia focuses on how to respond when quality of life is severely challenged and older people are unable to remain living in the community. The title of the most recent reforms in the aged care agenda in Australia, Living longer, Living Better, focuses on the importance of ‘adding life to years’ advocated by the WHO. The shift to consumer-directed home care packages recognises the importance of personal choice and control in managing care and maximising QOL. However, the policy refers to delivering quality services and better monitoring of the quality of services, but QOL is mentioned specifically only once when referring to the need to ensure more timely diagnosis of dementia to improve QOL.
Unfortunately, QOL concepts and quality of care are confused in residential aged care settings, and in Australia the focus is on service outcomes and meeting regulatory standards rather than assessing resident outcomes (Courtney, O’Reilly, Edwards, & Hassall, 2007). The proposed Australian Aged Care Quality Agency will monitor the quality of residential aged care facilities and the My Aged Care website will publish aged care quality indicators and rating systems. However, it is not clear whether these new structures will shift the focus to measuring resident outcomes in terms of QOL. The truism ‘what gets measured gets done’ applies in this context. Unless QOL is systematically monitored in service delivery and community settings, it is unlikely to be a driver in service design and delivery and policy making.
Principles for ensuring QOL in aged care policy and services
We propose that all services and programs targeted towards older people need to observe the following principles.
- Improvements in the health and wellbeing of older people are achievable and necessary through the use of psychological and behavioural interventions.
- Preventive and health enhancing principles should underpin all services for older people, both in the community and in residential aged care settings.
- Service design needs to incorporate approaches that cater for individual differences in ageing experiences and outcomes and client-centred approaches. A ‘one-size-fits-all’ approach is unlikely to be successful.
- Services should incorporate QOL measures in their minimum data set and report against them as a key performance indicator in their outcome measurement reports.
Psychology and psychologists have made an important contribution to the conceptualisation, measurement and promotion of QOL and related constructs for older people. However, within the broader aged care and health service systems much greater focus on these is required to ensure that ‘life’ is truly added to the longevity for older people.
The principal author can be contacted at [email protected]