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. 2023 Apr 8;64(4):gnad041. doi: 10.1093/geront/gnad041

The Association of Self-Perception of Aging and Quality of Life in Older Adults: A Systematic Review

Vithya Velaithan 1,2,✉, Min-Min Tan 3,4, Ting-Fai Yu 5, Andrian Liem 6, Pei-Lee Teh 7, Tin Tin Su 8,9
Editor: Patricia C Heyn
PMCID: PMC10943510  PMID: 37029753

Abstract

Background and Objectives

Self-perception of aging is an important psychosocial factor that can influence quality of life in older age. This review aimed to synthesize findings on the association between self-perception of aging and quality of life among older adults aged 60 and above.

Research Design and Methods

A systematic search was conducted in 4 electronic databases (Ovid Medline, PsycInfo, CINAHL, and Web of Science). Studies conducted in English and including measures on the perception of aging and quality of life were included in this review. A total of 32 observational studies (21 cross-sectional, 8 longitudinal, 2 mixed-method, and 1 qualitative) met the inclusion criteria. Outcomes reported in the included studies were quality of life, physical health and functioning, psychological health, mental health, and general well-being.

Results

Overall, 20 quantitative studies indicated a strong association between positive perception of aging and increased quality of life. Similarly, 9 quantitative studies demonstrated that negative perception of aging is associated with lower quality of life. Results of the mixed-method and qualitative studies indicated that older adults with higher morale and good physical capability had more positive perceptions of health.

Discussion and Implications

These results suggest that promoting a positive perception of aging and a self-care attitude would help to enhance older adults’ quality of life and should be incorporated into future health promotions and interventions.

Keywords: Aging perception, Aging well, Attitudes toward aging, Life satisfaction, Quality of life

Population aging is a global phenomenon resulting mainly from reduced childhood mortality, falling fertility rates, and rising life expectancy (Beard et al., 2016). The proportion of those aged 60 and above is predicted to double from 12% in 2015 to 22% in 2050 (WHO, 2019). Life expectancy is expected to rise further, particularly in low- and middle-income countries (LMICs; Lee et al., 2020). Population aging has significant implications, particularly for healthcare, the labor market, pensions, housing, and social services. As life expectancy increases, quality of life (QoL) will be an important indicator of older adults’ well-being (Bosch-Farre et al., 2018; Lee et al., 2020).

Research on aging and QoL frequently focuses on preventing disease and impairment of physical and cognitive functions. Other factors such as psychological and social well-being are often neglected and the relationship between the psychosocial factors and the aging process is understudied. However, older adults experiencing a decline in health and physical functioning may still be able to maintain a good QoL in terms of their social and psychological well-being (Ailshire & Crimmins, 2011). Therefore, psychosocial aspects of well-being such as self-perception of aging (SPA), mental health, life satisfaction, and social resources are vital elements to consider when measuring the QoL of older adults (Ailshire & Crimmins, 2011; McKee & Schuz, 2015).

SPA is the belief and expectations held by an older individual about their own aging (Levy et al., 2002a, 2002b). SPA is also known as subjective aging, attitude towards own aging (ATOA) and aging expectations in the literature (Diehl et al., 2014). Other constructs also evaluate perception of aging such as acceptance of aging, which is suggested to be an important part of older adults coping mechanism with age-related changes (Ranzijn & Luszcz, 1999). The stereotype embodiment theory hypothesizes that the expectations about aging develop over the life span by accumulating and internalizing societal views and stereotypes about aging (Levy, 2009). The internalized stereotypes then become self-fulfilling prophecies that manifest as SPA. Individuals interpret their aging experience through SPA, particularly when they experience critical age-related processes, such as declining health and physical functioning. SPA exerts its effect on health outcomes via three pathways: psychological pathway (expectations generated by SPA function as self-fulfilling prophecies), behavioral pathway (health promotion via health-seeking behavior and physical activity), and physiological pathway (increased immunocompetency; Levy, 2009).

The internalization of positive or negative stereotypes influences older adults’ SPA, which predicts health and well-being in old age (Levy et al., 2002a, 2002b; Sarkisian et al., 2002). Several studies have established that positive SPA is advantageous for various health outcomes. Positive SPA has been associated with better physical functioning (Levy et al., 2002a, 2002b; Sargent-Cox et al., 2012a), increased survival (Levy et al., 2002a, 2002b; Sargent-Cox et al., 2014), life satisfaction (Montepare & Lachman, 1989; Steverink et al., 2001), better self-reported mental health (Kim, 2009), and self-rated health (SRH; Moor et al., 2006). In contrast, having more negative SPA is associated with poor health outcomes such as impaired physical functioning (Levy et al., 2002a, 2002b), reduced motivation to survive (Levy et al., 2002a, 2002b), and decreased cognitive function (Hess et al., 2003). Given the positive contribution of SPA to health and well-being, its contribution towards QoL should be systematically investigated.

Previous systematic reviews on SPA had focused on older adults residing in predominantly western, high-income nations (United States, Europe, and Australia; Tully-Wilson et al., 2021; Warmoth et al., 2016). Moreover, the reviews also focused on longitudinal studies and health-related outcomes, including survival (Meisner, 2012; Tully-Wilson et al., 2021; Warmoth et al., 2016). However, a systematic investigation on how SPA contributes to overall QoL among older adults is lacking. Therefore, the current review includes observational studies of quantitative, mixed-method, and qualitative nature across various population groups. Moreover, QoL and its domains such as physical health and functioning, psychological health, mental health, and general well-being were also included in this review. Hence, the current study aims to review existing evidence regarding the possible linkage of SPA and QoL by addressing the question: What is the association between SPA and QoL among older adults?

Method

Protocol

This systematic review was prepared according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist (Page et al., 2021). This review’s protocol has been submitted to the International Prospective Register of Systematic Reviews (PROSPERO; Registration number: CRD42020180386).

Study Eligibility Criteria

Studies investigating the association between SPA and QoL in older adults that met the following criteria were included: (a) Older adults aged 60 years and above; (b) studies that measured older adults’ SPA and related predictors such as attitudes towards aging, subjective aging, and aging stereotypes; (c) studies that measured QoL and its domain, SRH, life satisfaction, and well-being measures; and (d) studies conducted in English published in peer-reviewed journals.

We excluded studies (a) with participants aged below 60 years; (b) studies that included both younger (<60) and older participants (≥60) were excluded, (c) studies that included SPA only or QoL only, (d) not published in English; and (e) that were not observational such as RCTs, reviews/meta-analysis, and metaethnographic.

Electronic Database Searches

Systematic searches of Ovid Medline, PsycInfo, CINAHL, and Web of Science were conducted in March 2021 with the coverage included studies published between March 2011 and March 2021. The search was further updated in December 2022 by following the same protocol. The search strategy included MeSH terms, keywords, and free terms related to the topic of this systematic review. Boolean operators (OR, AND) were used to combine the search terms. Wild card and truncation options were used whenever appropriate. The search strategy used the following Boolean descriptors: (self-perception of ageing OR ageing perception OR stereotype behavior OR attitude towards ageing OR stereotype attitude OR self-stereotype OR self-concept OR ageing experience OR ageing stereotype OR perceived age OR subjective ageing) AND (older adults OR elderly OR old OR ageing OR old age OR older person) AND (quality of life OR WHOQOL OR WHOQOL-BREF OR CASP-19 OR SF-36 OR hrqol OR health-related quality of life OR EQ-5D OR Euroqol OR wellbeing OR wellbeing OR life satisfaction OR self-rated health). The search strategy was developed in Ovid MEDLINE and adapted for other databases. All searches were exported into EndNote, and duplicates were removed.

Study Selection

The literature search resulted in 6,074 publications. The elimination of duplications, using the EndNote reference manager, resulted in an initial exclusion of 953 references, with 5,121 records retained. One member of the team (V. Velaithan) independently screened the records by reading the content of the title, abstract, and keywords, resulting in the exclusion of 4,999 documents. The full text of the 122 documents was reviewed by one reviewer (V. Velaithan) leading to the rejection of a further 92 documents. In the updated search from April 2021 to December 2022, a total of 460 articles were retrieved and their title and abstract were screened. Five articles were included in the full-text review with only two being included in the final review. The first author (V. Velaithan) also obtained a second opinion during the article screening and retrieval process and consulted with the second author (M.-M. Tan) and senior author (T. T. Su) during this process. The PRISMA flowchart detailing the study selection and inclusion is shown in Figure 1.

Figure 1.

Figure 1.

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Article selection process according to PRISMA 2020 guidelines.

Quality Assessment

Cross-sectional and longitudinal cohort studies were evaluated using an adapted Newcastle–Ottawa Scale (NoS). Mixed-method appraisal tool (MMAT) was used to appraise mixed-method studies. The qualitative studies in this review were appraised using Joanna Briggs Institute (JBI) checklist for qualitative studies. The risk of bias for cross-sectional and longitudinal cohort studies was assessed based on scores in the selection, comparability, and outcome domains in the NOS scale. A study was considered to have low risk of bias if it had 4 or 5 points in the selection domain, 2 points in the comparability domain, and 2 points in the outcome domain. Studies were regarded as having an intermediate risk of bias if they had 4 or 3 points in the selection domain, and 1 or 2 points in the comparability or outcome domain. Finally, high risk of bias was assigned to other combinations of points. The quality assessment was independently performed by three reviewers, V. Velaithan, M.-M. Tan, and T.-F. Yu and discrepancies were discussed to obtain final quality scores.

Data Extraction and Analysis

A narrative synthesis approach was employed to identify and comprehend the quantitative and qualitative findings. For quantitative studies, the extracted data included study and participant characteristics (study design, participant details, SPA measurement tool, QoL measurement tool, association between SPA and QoL in terms of the reported beta coefficient, 95% confidence interval, or standard error (SE), and adjustment for confounders). Meta-analysis was not conducted as the outcome measures were heterogeneous. One author (V. Velaithan) extracted the main findings related to perception of aging and its relationship with QoL for qualitative study findings. Main themes presented in each study were also extracted. The quantitative results of the mixed-method study were also extracted and analyzed thematically.

Results

The searches retrieved 6,534 articles, from which 973 duplicates were removed. A total of 127 articles were included for full-text screening following the title and abstract search (Figure 1). After the full-text screening, a total of 32 articles (21 cross-sectional, eight longitudinal, two mixed methods, and one qualitative) were included in this review.

Study Characteristics

The characteristics of cross-sectional studies are shown in Table 1. The included studies had sample sizes ranging from 120 to 7,229 participants, with a mean age between 64.5 and 74.0. Most of the studies recruited community-dwelling participants, with only two studies recruiting participants from hospitals or clinics (Gu et al., 2019; Hou et al., 2020). The majority of studies (13 of 20 studies) have been conducted in Asia, including countries such as China (n = 6), Turkey (n = 4), Japan (n = 2), and Korea (n = 1). One study involved multicountry participants. One study was conducted in Australia (n = 1). Five studies were done in Europe and North America, including France (n = 2), Netherland (n = 1), and Canada (n = 2). Only one study was conducted in Africa, which was in Nigeria (n = 1).

Table 1.

Details of Cross-Sectional Studies Included in the Systematic Review (21 Studies)

Study Country Sample size % Female Age range, mean age ± SD Perception of aging measure Quality-of-life measure Results Risk of bias
Bai et al. (2017) China 1,099 48% 60–96
69.6 ± 7.0		 Self-image of aging scale (SIAS-C) Life satisfaction (SWLS) Self-image was positively associated with life satisfaction (β = 0.299, p < .001). Low
Bryant et al. (2012) Australia 421 61.5% Aged ≥ 60
71.67 ± 7.93		 AAQ Life satisfaction (SWLS)
Depression (CES-D)
Physical and mental health (SF-12)		 Positive attitudes to aging were associated with higher levels of satisfaction with life, better self-report physical and mental health on the SF-12, and lower levels of anxiety and depression. Low
Cadmus et al. (2021) Nigeria 1,180 82.3% Aged ≥ 60 AAQ SRH Urban-dwelling participants had a better attitude to the aging process in all the domains compared with rural-dwelling participants. Among both rural and urban older adults, good self-rated health was significantly associated with a positive attitude to aging across the domains. Intermediate
Chen et al. (2021) China 7,229 45.8% Aged ≥ 60
68.99 ± 7.40		 AAQ Life satisfaction (single item question)
Depression (CES-D)
loneliness (Loneliness scale)		 Older people experiencing psychosocial loss are less satisfied with their life (β = −0.036, SE = −0.003, p < .001), more depressed (β = 0.327, SE = 0.010, p < .001) and lonely (β = 0.096, SE = 0.004, p < .001). Low
Cramm et al. (2018) Netherlands 680 47.6% 66–95
72.90 ± 5.02		 APQ-S Physical and social well-being (SPF-IL) SPA is positively associated with well-being. Low
Dogra et al. (2015) Canada 170 79% 60–87
70.9 ± 6.8		 Aging expectation (AE) physical and mental health (SF-36)
Physical activity (Healthy Physical Activity Participation Questionnaire)		 Higher AE scores significantly associated with better mental health (β = 0.23, SE = 0.08, p = .003), and higher physical activity (β = 0.04, SE = 0.01, p = .003). Intermediate
Emile et al. (2014) France 192 59.4% 60–93
73.44 ± 7.34		 ATOA Physical activity (Dijon Physical Activity Score) Positive stereotypes regarding physical activity directly predicted physical activity and indirectly by attitude towards own aging (β = 0.13, p < .05. Low
Fukase et al. (2018) Japan 572 51.7% Aged ≥ 65 Acceptance of aging scale life satisfaction (LSIK-J) Acceptance of aging was negatively related to QOL (β = −0.19, SE = 0.29, p < .05). High
Gu et al. (2019) China 1,029 50.1% Aged ≥ 60
69.68 ± 8.49		 APQ QoL (SF-36) Negative SPA associated with lower QOL Low
Hou et al. (2020) China 1,029 50.1% Aged ≥ 60
Urban = 68.4 ± 7.5
Rural = 70.8 ± 9.2		 APQ QoL (SF-36) Older adults with negative SPA and living in rural area had poorer HRQoL. Low
Korkmaz Aslan et al. (2019) Turkey 999 50.4% Aged ≥ 65
72.34 + 23.61		 AAQ QoL (WHOQOL-OLD) Positive attitudes to aging predicts better QOL. AAQ subscales psychosocial loss (β = −0.289, p < .001), physical change (β = 0.296, p < .001), and psychological growth (β = 0.279, p < .001) were significant predictors of quality of life. Low
Liu et al. (2020) China 5,809 (secondary data from CLASS) 45.1% Aged ≥ 60 AAQ life satisfaction (single item measure) Attitudes toward aging directly influences life satisfaction of older adults (β = 0.07, p < .001) Low
Low et al. (2013) Multicountry 4,593 42.8% 60–100
72.1		 AAQ QoL (WHOQOL-BREF) Attitudes to aging subscales, physical change (β = 0.122, p < .01), psychosocial loss (β = .102, p < .01), and psychological growth (β = 0.024, p < .01) mediate the effect of health satisfaction on QOL. Low
Marquet et al. (2019) Canada 151 NA 60–80
68.75 ± 5.38		 Fear of aging scale
negative age stereotype		 Self-esteem (The Rosenberg Self-Esteem Scale) Negative SPA predicted an older subjective age (β = 0.24, p < .001), and lower self-esteem (β = 0.10, p = .05). Low
Suh et al. (2012) Korea 405 50.4% Aged ≥ 65
73.01 ± 4.95		 Differential scale Life satisfaction Better knowledge (β = 0.12, p = .008) and better attitude about aging (β = −0.22, p = .001) increased life satisfaction. High
Stephan et al. (2011) France 250 74.4% 60–77
64.52 ± 1.85		 Subjective age Life satisfaction (SWLS)
subjective health
Memory self-efficacy		 Youthful subjective age is related to higher memory self-efficacy (β = 0.19, p = .01) and higher life satisfaction (β = 0.15, p = .05). Intermediate
Takatori et al. (2019) Japan 3,094 52% 65–98
72.9 ± 6.2		 Self-perceived age SRH Younger self-perceived age leads to better self-rated health (β = −0.083, p < .01). Intermediate
Top et al. (2012a) Turkey 120 36.7% 65–90
74.02 ± 7.24		 AAQ QoL (WHOQOL-OLD) Attitudes to aging dimensions, psychosocial loss (β = 1.015, SE = 0.078, p < .001), Physical change (β = 1.097, SE = 0.086, p < .001) and psychological growth (β = 0.501, SE = 0.073, p < .001) had a significant positive relationship with QoL. High
Top et al. (2012b) Turkey 270 100% Aged 60–98
67.03 ± 6.60		 AAQ QoL (WHOQOL-OLD) Physical change (β = 0.296, SE = 0.130, p = .023) and psychological growth (β = 0.815, SE = 0.125, p = .000) dimensions of attitudes toward aging were significant predictors of QOL in the women. High
Top et al. (2012c) Turkey 550 49.1% Aged 60–109
68.03 ± 6.55		 AAQ QoL (WHOQOL-OLD) Two domains of attitudes toward aging, physical change (β = 0.425, SE = 0.094, p = .000) and psychological growth (β = 0.816, SE = 0.087, p = .000) were significant predictors of QOL. High
Zhang et al. (2018) China 279 48.7% Aged 60–97
67.09 ± 6.29		 18-item image of aging scale Life satisfaction (LSI-A) Positive aging stereotypes (PAS; β = 0.21, p < .001) and negative aging stereotypes (β = −0.14, p < .01) significantly associated with life satisfaction. Low
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Notes: AAQ = attitudes to aging questionnaire; APQ = aging perception questionnaire; APQ-S = aging perceptions questionnaire–short version; ATOA = attitude towards own aging; CES-D = Center for epidemiological studies depression; LSI-A = life satisfaction index-A; LSIK-J = life satisfaction index K in Japanese; SF-12 = 12-item short form health survey; SF-36 = short form 36; SPA = self-perception of aging; SPF-IL = social production function instrument for the level of well-being short; SRH = self-rated health; SWLS = satisfaction with life scale.

Table 2 details the eight longitudinal studies included in this review. The studies had a follow-up period ranging from 6 months to 16 years. Sample sizes range from 101 to 4,175 participants, with a mean age of 70–80.8. Study participants were recruited from the community, and only two studies recruited participants from hospitals (Levy et al., 2019; Schroyen et al., 2017). Studies were done in six countries, Germany (n = 3), France (n = 1), Belgium (n = 1), USA (n = 1), Australia (n = 1), and Israel (n = 1).

Table 2.

Details of Longitudinal Studies Included in the Systematic Review (8 Studies)

Study Country Sample size % Female Follow-up (years) Age range, mean age Perception of aging measure Quality-of-life measure Main findings Risk of bias
Beyer et al. (2015) Germany 309 41.7% 2.5 65–85
73.27 ± 5.1		 ATOA SRH (single item question)
Physical activity (IPAQ)		 Baseline positive SPA is associated with better SRH (β = 0.26, SE = 0.09, p = .005). Low
Beyer et al. (2019) Germany 4,175 43% 3 65–93
73 ± 5.61		 AgeCog battery Physical activity (single item question) Negative SPA associated with lower physical functioning (β = −0.06, SE = 0.03, p = .04). Low
Emile et al. (2015) France 192 87.5% <1 (9 months) 60–92
73.22 ± 7.53		 ATOA
aging stereotypes and exercise scale		 Subjective vitality (subjective vitality scale) Age stereotypes about benefits of physical activity and positive SPA associated with better subjective vitality (β = 0.21, p < .05). Low
Levy et al. (2019) USA 189 41% 1 60–95
70 ± 7.5		 Stereotype predictors Myocardial infarction (MI) recovery rate Positive stereotypes about being older predicted better MI recovery (β = 0.02, SE = 0.01, p = .03). High
Sargent-Cox et al. (2012b) Australia 1,212 48.4% 16 65–103
76.89 ± 6.12		 ATOA Physical functioning (EPESE) Poor SPA are associated with decline of physical functioning (β = 0.28, SE = 0.07, p < .001). Low
Schroyen et al. (2017) Belgium 101 54% 1 Aged 73.5 ± 6.2 AAQ Cancer quality-of-life questionnaire (EORTC-QLC) Negative SPA, and negative view of cancer associated with worse physical (β = 0.4, SE = 0.07, p < .001) and mental (β = 0.53, SE = 0.07, p < .001) health outcomes. Low
Tovel et al. (2019) Israel 1,216 45.7% 2 75–96
80.85 ± 3.91		 ATOA Physical functioning (FL, ADL, IADL) SPA had positive effect on physical functioning (β = 0.24, SE = 0.039, p < .001) Low
Wurm et al. (2013) Germany 309 41.7% <1 (6 months) Aged ≥ 65
73.27 ± 5.1		 Negative SPA SRH
life satisfaction (SWLS)
Physical functioning (10-item Physical Functioning subscale of the SF-36)		 Negative SPA associated with lower physical functioning (β = −5.38, SE = 2.11, p < .05) and SRH (β = −0.17, SE = 0.08, p < .05) and life satisfaction (β = −0.33, SE = 0.12, p < .001). Low
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Notes: ADL = activities for daily living; EORTC-QLC-C30 = European organization for research and treatment of cancer quality-of-life questionnaire core 30; EPESE = epidemiological research in the elderly; FL = functional limitation; IADL = instrumental activities of daily living scale; IPAQ = international physical activity questionnaire; SF-36 = short form 36; SRH = self-rated health; SWLS = satisfaction with life scale.

The mixed-method and qualitative study characteristics are presented in Table 3. The studies had sample sizes ranging from 52 to 225 participants. All studies included community-dwelling participants and one of the studies also included participants from nursing homes. Studies were conducted in Sweden, Germany, and Britain.

Table 3.

Details of Mixed-Method and Qualitative Studies Included in the Systematic Review (Three Studies)

Study Country Study design Participant details Data collection method Data analysis approach Quantitative results Qualitative results (key themes)
Almevall et al. (2021) Sweden Mixed method 52 older adults
>80 years old
61.5% female		 Quantitative: PGCMS questionnaire
Qualitative: Interview		 Inductive, qualitative content analysis
MM-triangulation		 Mean morale in men: 14.0 ± 1.6
Mean morale in women: 12.8 ± 2.5
PGCMS is significantly associated with age (β = 0.365, p = .038) and ADL (β = −0.394, p = .008).		 (i) Included or excluded in social context
(ii) Good or declined health
(iii) Physically active or passive
(iv) At home or feeling homeless
(v) Engagement or lack of interest
(vi) Freedom or captivity
Miche et al. (2014) Germany Mixed method 225 older adults
Aged 70–88
Mean age: 77.1 ± 5.0
57.8% female		 Quantitative: questionnaires on positive affect (pa), negative effect (na), valuation of life (Freeman et al., 2016)
single item question on life satisfaction (ls)
Qualitative:
one-page daily diary report on subjective aging experiences (SAE)		 Directed qualitative content analysis Aggregated positive SAE is significantly associated with PA (β = 0.20, p < .05)
Aggregated negative SAE is significantly associated with NA (β = 0.19, p < .05).
No association between SAE and life satisfaction (β = 0.12/β = −0.09).
Aggregated negative SAE associated with lower VOL (β = −0.22, p < .01).		 (i) Health and physical functioning
(ii) Cognitive functioning
(iii) Interpersonal relations
(iv) Social–cognitive and social–emotional functioning
(v) Lifestyle and engagement
Parsons et al. (2014) Britain Qualitative 2 British cohorts
60 older adults
Aged 64–79
Mean age = 74.7		 Semistructured interview Thematic analysis NA Advantages: financial security, having life experience, freedom, enjoying grandchildren and family, good health, and feeling respected by others.
Disadvantages: general physical decline, slowing up, being closer to dying, having less energy, not being respected, fear of the future, being left behind as friends and family die off, having a poor memory
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Except for one study that investigated only women (Top et al., 2012b), the rest of the studies included both men and women, in which the proportion of women ranged from 36.7% (Top et al., 2012a) to 87.5% (Emile et al., 2015).

Self-Perception of Aging Measures

The commonly used validated SPA measures in the quantitative studies were attitudes to aging (AAQ; Laidlaw et al., 2007; eight studies; Bryant et al., 2012; Cadmus et al., 2021; Chen et al., 2021; Korkmaz Aslan et al., 2019; Liu et al., 2020; Low et al., 2013; Schroyen et al., 2017; Top et al., 2012a, 2012b, 2012c), attitudes towards own aging (ATOA) from the PGCMS (Lawton, 1975; five studies; Beyer et al., 2015; Emile et al., 2014, 2015; Sargent-Cox et al., 2012a; Tovel et al., 2019), and APQ (Barker et al., 2007; three studies; Cramm & Nieboer, 2018; Gu et al., 2019; Hou et al., 2020). Other measures that were less commonly used were the self-image of aging scale (SIAS-C; Bai et al., 2017), AgeCog battery (Beyer et al., 2019), aging expectation (Dogra et al., 2015), negative SPA measure (Wurm et al., 2013), differential scale (Suh et al., 2012), fear of aging scale (Marquet et al., 2019), and the 18-item image of aging scale (Zhang et al., 2018). The nonvalidated measures used were the acceptance of aging (Fukase et al., 2018), stereotype predictors (Levy et al., 2019), subjective age (Stephan et al., 2011), and self-perceived age (Takatori et al., 2019).

Quality-of-Life Measures

The outcome measures reported in the included studies were general QoL, physical health and functioning, psychological health, mental health, and general well-being (Chen et al., 2012; Netuveli & Blane, 2008; Table 4). Various instruments were used to evaluate QoL including WHOQOL-OLD (Korkmaz Aslan et al., 2019; Top et al., 2012a, 2012b, 2012c), WHOQOL-BREF (Low et al., 2013), health-related QoL (HRQoL; Gu et al., 2019; Hou et al., 2020), and cancer-related QoL measure, EORTC-QTC (Schroyen et al., 2017). Physical health and functioning-related outcomes were assessed using a heterogenous measurement tool for SRH, physical activity, physical functioning, and myocardial infarction (MI) recovery rate. Single item questionnaire for SRH was used in four studies (Beyer et al., 2015; Emile et al., 2015; Takatori et al., 2019; Wurm et al., 2013). Physical activity was measured using IPAQ (Beyer et al., 2015), single item questionnaire on doing sports and walking (Beyer et al., 2019), and Dijon Physical Activity Score (Emile et al., 2014). Physical functioning was measured using Epidemiological Research in the Elderly (EPESE) battery (Sargent-Cox et al., 2012b), functional limitation (Low et al., 2013), activities of daily living (ADL), instrumental activities of daily living (IADL; Tovel et al., 2019) 10-item physical functioning subscale of the SF-36 (Wurm et al., 2013), and MI recovery rate (Levy et al., 2019). Psychological health-related outcomes were measured using life satisfaction (Bai et al., 2017; Chen et al., 2021; Fukase et al., 2018; Liu et al., 2020; Stephan et al., 2011; Suh et al., 2012; Wurm et al., 2013; Zhang et al., 2018) and self-esteem (Marquet et al., 2019). Mental health-related outcomes were evaluated using memory self-efficacy (Stephan et al., 2011), self-reported mental health (SF-36), depression, and loneliness. General well-being was measured using physical and social well-being (SPF-IL) scale (Cramm & Nieboer, 2018) and subjective vitality scale (Emile et al., 2015).

Table 4.

QoL Measures and Their Specific Domains

QoL measures Specific domains No of studies References
General QoL (n = 8) Overall QoL 5 Korkmaz Aslan et al. (2019); Low et al. (2013); Top et al. (2012a,
2012b)
Health-related QoL 2 Gu et al. (2019); Hou et al. (2020)
Cancer-related QoL 1 Schroyen et al. (2017)
Physical health and functioning (n = 12) Self-rated health 4 Beyer et al. (2015); Cadmus et al. (2021); Takatori et al. (2019); Wurm et al. (2013)
Physical functioning 3 Sargent-Cox et al. (2012b); Tovel et al. (2019); Wurm et al. (2013)
Physical activity 4 Beyer et al. (2019); Beyer et al. (2015); Dogra et al. (2015); Emile et al. (2014)
MyocardiaI infarction recovery rate 1 Levy et al. (2019)
Mental health (n = 6) Memory self-efficacy 1 Stephan et al. (2011)
Self-rated mental health 2 Bryant et al. (2012); Dogra et al. (2015)
Depression 2 Bryant et al. (2012); Chen et al. (2021)
Loneliness 1 Chen et al. (2021)
Psychological health (n = 10) Life satisfaction 9 Bai et al. (2017); Bryant et al. (2012); Chen et al. (2021); Fukase et al. (2018); Liu et al. (2020); Stephan et al. (2011); Suh et al. (2012); Wurm et al. (2013); Zhang et al. (2018)
Self-esteem 1 Marquet et al. (2019)
General well-being (n = 2) Physical and social well-being 1 Cramm & Nieboer (2018)
Subjective vitality 1 Emile et al. (2015)
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Note: QoL = quality of life.

Mixed-Method and Qualitative Study Data Collection

The first mixed-method study utilized the Philadelphia Geriatric Centre Morale Scale (PGCMS) questionnaire to assess the participants’ morale. In the qualitative part of the same study, participants were asked to explain further about how satisfied they were with their lives (Almevall et al., 2021). The second mixed-method study used daily diary method for data collection of both quantitative and qualitative assessment and recorded the subjective aging experiences related to five domains of behavior and functioning (Miche et al., 2014). The only qualitative study included in this review utilized a semistructured interview method by asking participants about the advantages and disadvantages of being older (Parsons et al., 2012).

Results of Quantitative Studies

Relationship between SPA and general quality of life

Eight studies (29.6%) examined SPA and its association with general QoL. Five studies found positive SPA was associated with better QoL (β ranged from 0.024 to 1.097), whereas three found a negative association between negative SPA and QoL.

Seven cross-sectional studies examined the association between SPA and QoL. Studies conducted in Turkey showed that attitude towards aging had a significant positive relationship with QoL (Korkmaz Aslan et al., 2019; Top et al., 2012a, 2012b, 2012c). Similarly, in a multicountry study, SPA mediated the effect of health satisfaction on QoL, and the results were consistent across all populations from 20 countries regardless of gender and age (Low et al., 2013). In contrast, Chinese older adults residing in rural areas with hypertension had more negative SPA and lower health-related QoL than older adults from urban areas (Gu et al., 2019; Hou et al., 2020). Only one longitudinal study investigated the association between SPA and QoL. This study reported that negative SPA at baseline was associated with poorer physical and mental health outcomes (Schroyen et al., 2017). These findings indicate that positive SPA is associated with better QoL, whereas negative SPA is associated with lower QoL in diverse populations.

Relationship between SPA and physical health and functioning

Nine studies investigated the association between SPA and physical health and functioning, including outcome measures such as SRH, physical functioning, physical activity, and MI recovery rate. Six studies found a positive association between positive SPA and physical health and functioning (β ranged from 0.02 to 0.28). In contrast, three studies found a negative association between negative SPA and physical health and functioning.

There were four cross-sectional studies investigating SPA and physical health and functioning. Among Japanese older adults, younger self-perceived age was related to higher SRH (Takatori et al., 2019). Positive SPA was also associated with better SRH among urban and rural older adults in Nigeria (Cadmus et al., 2021). A French study indicated that positive age stereotypes, particularly regarding physical activity, predicted physical activity levels (Emile et al., 2014). Better aging expectations also led to increased participation in physical activities among older adults with lower socioeconomic status (Dogra et al., 2015).

Six longitudinal studies examined the relationship between SPA and physical health and functioning. A study conducted in Germany reported that older adults with more positive SPA at baseline had higher physical activity and better SRH after 2.5 years. Similarly, a study in Israel reported that a higher score in SPA at baseline was associated with better physical functioning after 2 years (Tovel et al., 2019). Moreover, older adults with positive stereotypes about being older had a higher MI recovery rate than those with positive stereotypes about younger age groups (Levy et al., 2019). Negative SPA on the other hand was associated with lower physical functioning and SRH (Wurm et al., 2013). A 16-year follow-up study among Australian older adults also showed a steep decline in physical functioning among those with poor baseline SPA (Sargent-Cox et al., 2012b). Overall, both cross-sectional and longitudinal studies highlight the benefits of having a more positive perception of aging on improving physical health, recovery from chronic health conditions, and promoting physical activity among older adults.

Relationship between SPA and psychological health

Ten studies (eight cross-sectional and one longitudinal) investigated the association between SPA and psychological health, including outcome measures such as life satisfaction and self-esteem. Overall, five studies reported a positive association (β ranged from 0.07 to 0.21), while four reported a negative association between SPA and psychological health outcomes.

Cross-sectional studies among Chinese older adults reported that SPA was positively associated with life satisfaction, and in contrast, those with negative SPA are more prone to feeling unsatisfied with their life (Bai et al., 2017; Chen et al., 2021; Liu et al., 2020; Zhang et al., 2018). Similarly, among Korean and Australian older adults, those with a more positive SPA showed higher life satisfaction (Bryant et al., 2012; Suh et al., 2012). A French study also demonstrated that younger subjective age was related to higher life satisfaction (Stephan et al., 2011). In contrast, a study in Japan revealed a negative association between acceptance of aging and life satisfaction (Fukase et al., 2018). Negative SPA was also associated with lower self-esteem among Canadian older adults (Marquet et al., 2019). In a sole longitudinal study, German older adults with negative SPA reported lower life satisfaction (Wurm et al., 2013). These studies indicated that positive SPA, positive attitude, better aging knowledge, better self-image, and feeling younger were associated with better psychological health among culturally diverse older adults.

Relationship between SPA and mental health

Four cross-sectional studies explored the association between SPA and mental health, with two studies reporting a significant positive association. A study among multiethnic older adults with low socioeconomic status indicated that better aging expectations were related to better mental health (Dogra et al., 2015). Similarly, having positive SPA was also associated better mental health outcomes including lower levels of anxiety and depression among Australian older adults (Bryant et al., 2012). In another study, having youthful subjective age was associated with higher memory self-efficacy (Stephan et al., 2011). In contrast, negative SPA was associated with higher rates of depression and loneliness (Chen et al., 2021). Therefore, these studies indicate that positive SPA, better aging expectation, and youthful subjective age led to better mental health in terms of less depression and loneliness and increased belief in one’s memory efficacy.

Relationship between SPA and general well-being

Two cross-sectional studies investigated the association between SPA and general well-being. The first study, looking at aging perceptions for the well-being among Turkish migrant older adults in Rotterdam, reported that positive aging perceptions was related to well-being (Cramm & Nieboer, 2018). Another study shows that French older adults who had regularly been involved in physical activity, had better SPA, leading to better subjective vitality (Emile et al., 2015).

Results of mixed-method and qualitative studies

This review included two mixed-method studies and one qualitative study (Almevall et al., 2021; Miche et al., 2014; Parsons et al., 2012). The first mixed-method study investigated the perception of aging among older adults and psychological well-being or identified as morale. Morale was assessed with PGCMS tool, an assessment specific for older adults’ psychological well-being. The results show that participants with high morale rated their health as good whereas loneliness was associated with participants with low morale (Almevall et al., 2021). The quantitative and qualitative findings of the study revealed four themes related to perceptions of aging and well-being. These included not feeling lonely and being included, describing one’s health as good, having a high level of physical functioning, and living in one’s own home (Almevall et al., 2021). The second mixed-method study explored variances within subjective aging experiences of older adults and their association with outcomes such as positive affect, negative affect, life satisfaction, and valuation of life (Miche et al., 2014). The results indicated that although positive subjective aging experiences were significantly associated with positive effects, there was no significant association between subjective aging experiences and life satisfaction (Miche et al., 2014).

The qualitative study included in this review explored how older adults with good and poor physical capability regarded aging process, mainly focusing on differences in perceived advantages and disadvantages. Some benefits of older age mentioned were financial security, life experience, good health, more leisure time, not working, having a bus pass, freedom, and grandchildren. However, the study found that aging was frequently associated with physical decline and illness. Besides physical decline and illness, other disadvantages reported were slowing down, having less energy, developing arthritis, being treated as old, not respected, fearing future health problems, being closer to death, having poor memory, and feeling left behind (Parsons et al., 2012). Advantages such as having good health, life experience, and leisure time were mentioned more by those with good capability than those with poor capability. In contrast, the benefits of not working, having grandchildren and enjoying with them, and having bus passes were mentioned more by those with poor physical capability than those with good physical capability. Respondents mentioned financial security, or free from money worries, irrespective of their physical capacity (Parsons et al., 2012).

Quality assessment and risk of bias

Nineteen quantitative studies had a low risk of bias, four had intermediate risk, and six had a high risk. Studies with high risk of bias had lower scores in the selection and comparability domains. All the mixed-method studies (n = 2) scored above 80% in the MMAT quality assessment scale. The qualitative study was evaluated using JBI checklist and had a high score (Supplementary Table 1).

Discussion

This review included 30 observational studies examining the association between SPA and QoL. The quantitative studies (n = 27) highlighted the strong association between SPA and QoL, including key domains of QoL, physical health and functioning, psychological health, mental health, and general well-being. In total, 18 quantitative studies demonstrated the positive association between SPA and QoL, whereas nine showed the detrimental effects of negative SPA on the QoL.

The results of the included studies indicate that positive SPA was associated with increased QoL among older adults. Notably, studies reported that physical change and psychosocial loss domains of SPA (using the AAQ instrument) significantly predict QoL in older adults. A negative perception of aging was related to lower QoL among Chinese hypertensive older adults. A comparison between urban and rural hypertensive older adults also indicated rural older adults had poorer SPA and lower QoL. Rural older adults were found to have lower expectations of aging, and differences in socioeconomic factors between these groups were attributed to their differences in SPA and QoL. These results are consistent with other studies on the association of SPA with QoL (Hickey et al., 2010; Ingrand et al., 2018; Yamada et al., 2015). A prior study also implies that societal views on aging, predominantly negative stereotypes that encourage looking youthful well into old age, affect an individual’s SPA (Hickey et al., 2010). Differences in SPA are also known to arise due to differences in health status, socioeconomic status, societal perception, and living in either urban or rural areas. Therefore, addressing disparities, particularly socioeconomic differences, and improving the individual and social perception of aging would be beneficial in increasing older adults’ QoL.

The included studies highlight that positive SPA is associated with better SRH, increased physical activity, better physical functioning, and a better MI recovery rate. On the contrary, negative SPA is associated with declining physical functioning and lower SRH. These results agree with prior studies in which positive SPA was related to physical activity among community-dwelling older adults (Sarkisian et al., 2002; Wurm et al., 2010). SPA was thought to affect physical health via the behavioral and psychological pathways established in stereotype embodiment theory (Levy, 2009). In the first behavioral pathway, older adults with a positive view of aging will not think that health decline is inevitable with old age, so they are more likely to engage in physical activity to maintain their health (Beyer et al., 2015). The second proposed mechanism, via the psychological pathway, works mainly through self-efficacy or control belief. Self-efficacy is a vital resource for coping with age-related challenges. Thus, it was suggested that having more positive SPA increases self-efficacy, motivating people to be more active and utilize coping methods to maintain physical functioning (Tovel et al., 2019; Westerhof & Wurm, 2015; Wurm et al., 2013).

Positive SPA, positive attitude, better aging knowledge, better self-image, and feeling younger were all associated with better life satisfaction. In contrast, negative SPA, negative age stereotypes, and acceptance of aging were related to lower life satisfaction and lower self-esteem. SPA can affect life satisfaction as older adults with more positive SPA can adapt better to aging process (Chen et al., 2021). Secondly, feeling younger or youthful is related to having positive feelings towards one’s health which increases confidence in their capability and results in higher life satisfaction. In contrast, older adults with more negative SPA use fewer adaptation strategies to face life challenges. Thus, they are less likely to practice healthy behavior leading to poorer health outcomes and reduced life satisfaction (Wurm et al., 2008). A study from Japan reported that acceptance of aging is related to lower life satisfaction (Fukase et al., 2018). This is in contrast to prior study which indicated that acceptance of aging was related to better QoL (Ranzijn & Luszcz, 1999). However, the author points out, in the earlier studies, the participants were in a nursing home or having physical disability. On contrary, the Japanese older adults had higher scores in ADLs, lived in their own homes, and had good health, which might have made them less aware of their own aging. Therefore, the authors propose that acceptance of aging might be more useful for older adults people who are physically unwell and are severely restricted in their daily life.

Studies on the association of SPA with mental health revealed that positive SPA, including better aging expectations and youthful subjective age, was associated with better mental health and memory self-efficacy. In contrast, negative SPA was associated with depression and loneliness (Bryant et al., 2012). It was reported that older Chinese women with poorer SPA faced more loneliness and depression. This was related to older women having lower educational levels, poorer cognitive and economic resources, and longer life expectancy. Several mechanisms have been proposed for the way SPA affects mental health. First, having more negative perceptions lead to a pessimistic future outlook, which then evolves into stress, depression, and anxiety. Second, those with negative SPA are less likely to seek healthcare for depression and anxiety as they believe it is a normal part of aging (Freeman et al., 2016). Therefore, encouraging older adults to have a more positive outlook toward aging is vital to maintaining mental health and preventing depression.

The mixed-method and qualitative studies revealed that aging perception varies depending on older adults’ morale and physical capability. Having good physical health was mentioned more by older adults having high morale and better physical capability (Almevall et al., 2021; Parsons et al., 2012). These results support prior studies conducted in the United States whereby older adults from all ethnic groups mentioned that physical health was instrumental to aging well (Laditka et al., 2009). Similarly, qualitative studies conducted in Asia, particularly in Hong Kong and Sri Lanka, on older adults’ perception of aging also highlighted the importance of good health (Chong et al., 2006; Perera et al., 2015). Moreover, prior studies also indicate higher morale is associated with increased survival, absence of depression, and not feeling lonely (Niklasson et al., 2015, 2017).

The role of gender in SPA is rarely explored in the literature and there is no consensus on the presence of gender disparity. Majority of the studies included in this review did not explore gender differences in SPA. Few studies reported that there were no gender differences in SPA (Bryant et al., 2012; Sargent-Cox et al., 2012b; Top et al., 2012a, 2012b, 2012c; Tovel et al., 2019). One study explained that older women who experience psychosocial loss are more likely to feel unsatisfied with their life, more depressive, and lonelier than their male counterparts (Chen et al., 2021). In contrast, another study found women to have more positive SPA and higher life satisfaction (Suh et al., 2012). The mixed-method studies also explored gender differences in aging perception and reported contrasting results. Men were reported to have higher morale than women (Almevall et al., 2021). In another study, women were reported to have positive aging experiences in relationships and emotional domains but had more negative perceptions on physical and social engagement domains (Miche et al., 2014).

Implications

The findings of this review have significant implications for improving the QoL of older adults. This review has shown that improving older adults’ SPA positively affects QoL. Moreover, prior interventional studies have also demonstrated the possibility of modifying SPA to improve physical functioning in older adults. A 12-week randomized control trial (RCT) showed that including SPA as part of an intervention program to improve physical activity effectively improved SPA in the intervention group and improved physical performance and mental health (Beyer et al., 2019). Similar results have also been shown in other RCTs whereby improving the perception of aging increased physical activity among older adults (Levy et al., 2014; Wolff et al., 2014). The above studies show that improving SPA has tremendous benefits, particularly in improving physical health. Therefore, as highlighted by an earlier scoping review, the limited interventional studies examining ways to increase positive views of aging indicate the need for more studies in this area (Hausknecht et al., 2020).

Limitations and Strengths

Several limitations should be noted. The majority of the quantitative studies (70.4%) included in this review were cross-sectional and only eight were longitudinal studies. Therefore, it is impossible to conclude the directionality and causality. Secondly, the longitudinal studies generally had short follow-up periods, with an average of 1-year follow-up, and only 1 study had a 16-year follow-up period. As SPA is known to change over time, a longer follow-up will be helpful in understanding how maintaining positive SPA affects older adults’ QoL. Third, only eight studies investigated the relationship between SPA and general QoL, which means there is a lack of knowledge regarding the effect of SPA on overall QoL. Fourth, only articles written in English were included in this review; therefore, there is a possibility of publication bias. Another limitation in this review is the lack of studies from LMICs, particularly from Southeast and South Asia which would face the brunt of the aging population in near future. The studies included in this review, those from Asia were mainly from high-income (Japan, Korea) or upper-middle-income (China) countries. Also, there was only one study from Africa and none from South America. Therefore, there is limited understanding of how older adults in this region perceive aging and its impact on their QoL. Lastly, we would like to note that only one author conducted the screening and article retrieval process which could have increased the risk of selection bias. Despite the considerable evidence provided in this study regarding the positive effect of SPA on QOL and its domains, causal inferences cannot be drawn. Several methodological limitations need to be acknowledged, including the exclusion of articles indexed in other literature databases, which might have left out a significant number of related publications. Additionally, studies that included a mix age-group participants were also excluded. Moreover, about 20% of the included quantitative studies were showing a high risk of bias, particularly in the selection and comparability. Therefore, these findings should be interpreted with caution.

Despite the limitations, this study is able to provide comprehensive evidence on the relationship between SPA and QoL, including specific domains within QoL such as physical health, psychological health, mental health, and general well-being. Additionally, this review is able to contribute to existing research by outlining various measurements that could be useful to evaluate SPA including AAQ, APQ, and subjective age among others. Our review was also able to capture the benefits of SPA across wider population groups including those in Asia and Africa. The trends and gaps identified in this review will also be useful for future studies to design their research strategies tackling older adults’ perception of aging.

Conclusion

In conclusion, this systematic review synthesized the association between SPA and QoL from 32 observational studies in 15 countries across the globe. A positive association between SPA and QoL was found in the reviewed articles, including better QoL, improved physical health and functioning, better mental health, increased life satisfaction, and general well-being. In contrast, the detrimental effects of negative SPA were associated with a lower QoL, which also included a decline in physical functioning, lower life satisfaction, lower self-esteem, increased depression, and loneliness. Our results indicate the importance of SPA for older adults’ well-being and QoL. Future studies should consider longitudinal investigation on the benefits of maintaining positive SPA on older adults’ well-being and QoL. Additionally, studies should also be carried out among more vulnerable subset within older adults’ populations, particularly those living in LMIC, rural population, and older women. Therefore, our review suggests that there should be more effort to improve older adults’ perception of aging, which should be included in health interventions to improve their QoL.

Supplementary Material

gnad041_suppl_Supplementary_Material
gnad041_suppl_supplementary_material.docx (55.4KB, docx)

Contributor Information

Vithya Velaithan, Global Public Health, Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Bandar Sunway, Selangor Darul Ehsan, Malaysia; South East Asia Community Observatory (SEACO), Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Bandar Sunway, Selangor Darul Ehsan, Malaysia.

Min-Min Tan, Global Public Health, Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Bandar Sunway, Selangor Darul Ehsan, Malaysia; South East Asia Community Observatory (SEACO), Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Bandar Sunway, Selangor Darul Ehsan, Malaysia.

Ting-Fai Yu, School of Arts and Social Sciences, Monash University Malaysia, Bandar Sunway, Selangor Darul Ehsan, Malaysia.

Andrian Liem, Global Public Health, Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Bandar Sunway, Selangor Darul Ehsan, Malaysia.

Pei-Lee Teh, School of Business, Gerontechnology Laboratory, Monash University Malaysia, Bandar Sunway, Selangor Darul Ehsan, Malaysia.

Tin Tin Su, Global Public Health, Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Bandar Sunway, Selangor Darul Ehsan, Malaysia; South East Asia Community Observatory (SEACO), Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Bandar Sunway, Selangor Darul Ehsan, Malaysia.

Funding

This study was supported by the research grant from the GLOBAL ASIA in 21st CENTURY (GA21) PLATFORM, Monash University Malaysia. The author (V. Velaithan) was also funded by Graduate Research Merit Scholarship from Monash University Malaysia.

Conflict of Interest

None declared.

Data Availability

Additional data are available in the supplementary file.

Author Contributions

M.-M. Tan designed the study question; V. Velaithan conducted the literature search, article selection, data extraction, and wrote the manuscript; T. T. Su, P.-L. Teh, T.-F. Yu, M.-M. Tan, and A. Liem revised the manuscript, and provided critical recommendations on structure and presentation; all authors approved the final version of the manuscript.

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Data Availability Statement

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