Quality-of-life in older adults: its association with emotional distress and psychological wellbeing

Abstract

Background

There is consistent evidence of the impact of depression and health on Quality of Life in older adults. However, the influence of anxiety or psychological wellbeing aspects has been less extensively studied. This study aims to assess the association between quality of life and sociodemographic characteristics (gender, age), levels of health, emotional distress (anxiety and depression) and psychological wellbeing (personal growth and purpose in life).

Methods

The survey was conducted with 361 older adults (mean age = 68.44 years) This study was of cross-sectional design.

Results

We found that the older adults’ quality of life increased when increased the levels of health, personal growth and purpose in life and when there were lower scores in anxiety and depression. This model explained 63.2% of variance. In contrast, sociodemographic characteristics did not show any association with quality of life.

Conclusions

A better understanding of the factors associated with quality of life could help health professionals to develop interventions that enhance it. Efforts to address older adults’ quality of life focusing on older adults’ perceived health and emotional status should be considered.

Background

Although some older adults need informal care from their relatives or institutional care, most of them show adequate levels of independence [1]. The concept of Quality of Life is universally recognized as a critical metric in medical outcomes. It has been extensively explored and scrutinized in various fields of study, notably sociology and psychology. Previous scholarly inquiries into Quality of Life among older adults have predominantly concentrated on the prevalence and severity of health-related impairments within this group [2, 3]. Previous studies have found that self-perceived heath is related with Quality of life [3]. Moreover, the prevalence of chronic diseases among older people differs between men and woman, resulting in negative effects on Quality of life [4].

Models of Quality of life have been heavily influenced by a health approach, but broader Quality of life is more than health. Moreover, an exclusive emphasis on health-related aspects of Quality of Life (QoL) presupposes a normative framework regarding the QoL in individuals experiencing ill health. Such an equation of suboptimal health with diminished QoL fails to acknowledge the capacity of individuals to surmount health challenges and modify their life pursuits in alignment with their objectives. Additionally, the practice of extrapolating from patient or institutional cohorts to the broader elderly population may inadvertently confine older adults within the confines of a medicalized or socio-policy construct [2].

Quality of life is a multi-dimensional construct that includes various concepts including physical, social, and mental health, as well as life satisfaction and wellbeing. Older adults live more and better. Quality of life explores positive aspects of life at older ages. It is no appropriate to reduce Quality of life in older adults to physical components [2, 3].

Depression is a prevalent mental problem among European older adults (8%) [5] and it is often associated with lower quality of life. Depression could potentially have a negative impact on one’s Quality of Life. Previous review showed that depression is related to a reduced quality of life in older adults [3]. Older persons with depressive symptoms or a higher depressive symptom score had poorer Quality of Life and it seems that this relationship remains consistent over time. Following therapeutic intervention for depression, individuals exhibited an enhancement in their Quality of Life (QOL), a trend that was also observed in patients who did not achieve complete remission from their depressive episodes. As individuals age, there is a tendency to reconcile with the deterioration of health and functionality, a process influenced by both biological and psychosocial transformations. This reconciliation often involves the recalibration of expectations and internal benchmarks to mitigate the disparity between potential and actual circumstances, a phenomenon referred to as ‘response shift’. As a result, even in the absence of significant health improvements, individuals may perceive an elevated QOL during subsequent evaluations [6].

The contribution of anxiety to quality of life has received significantly less attention in the literature. This oversight may largely stem from the relatively nascent status of research on anxiety disorders in older adults, particularly when contrasted with the extensive body of work focused on depression. However, recent findings indicate that anxiety is the most prevalent (11%) mental health disorder among European community-dwelling older adults [5]. This revelation has heightened awareness regarding the necessity for further investigation into psychosocial issues and their associations, particularly concerning quality of life in the older adult population. Actually, a review showed that anxiety is related to a reduced quality of life among older adults in long-term care facilities [7].

The field of psychology ought to extend beyond the confines of psychopathology, such as depression and anxiety, and other manifestations of ill-being. Psychology has been encouraged to incorporate both the negative and positive facets of human experience. The domain of well-being is rooted in two extensive traditions: one focused on the concept of happiness (hedonic well-being), and the other centered around human potential (eudaimonic well-being). Despite the widely acknowledged distinction between positive and negative affect, certain studies employ depression measures to evaluate hedonic well-being. The eudaimonic tradition has refined the criteria for positive mental health, which are fundamentally affirmative in nature, contrasting with the definitions based on the absence of mental problems (such as depression and anxiety) that are prevalent in most mental health research and practice. The maximization of personal talents and capacities (personal growth) is a core element of this eudaimonic well-being model and aligns closely with Aristotle’s notion of personal excellence as the realization of one’s unique talents and capacities. Furthermore, a crucial endeavor in this context is the pursuit of meaning in one’s undertakings and challenges (purpose in life). The concept of quality of life inherently suggests a eudaimonic viewpoint of well-being. It is linked to an individual’s perception of satisfaction with life [2, 8].

Human need theory developed by Maslow posits that the extent to which human needs are fulfilled serves as a metric for quality of life [9]. The concept that humans function as ‘fulfillers of needs’ is a well-established principle in the field of psychology, as evidenced by Maslow’s work in 1968. When formulating the main theoretical models of Quality of Life, the authors have extensively referenced Maslow’s seminal work, ‘Toward a Psychology of Being’ [3]. Maslow’s contributions are significant for two primary reasons [2].

Firstly, akin to the behavioral psychologists who preceded him, Maslow positions the theory of need within a clearly defined ontological framework. He postulates that all individuals, by the mere fact of their humanity, inherently possess a universal set of needs. This shared set of needs, according to Maslow, is a fundamental aspect of human existence. Thus, his work provides a crucial theoretical underpinning for understanding human behavior and motivation.

Secondly, Maslow offers a critique of the ‘deficiency needs’ perspective, a viewpoint predominantly held by behavioral psychologists. He contends that this approach is excessively concentrated on the rudimentary necessities of human existence, such as the need for shelter, sustenance, clothing, and freedom from harm. In contrast to this perspective, Maslow’s theory posits that human beings are not solely preoccupied with ensuring their physical survival. Instead, once these basic needs have been met, individuals strive to fulfill higher-order needs. These include the pursuit of self-actualization, the attainment of happiness, and the desire for esteem. Thus, Maslow’s theory provides a more comprehensive understanding of human motivation, extending beyond mere survival to encompass the pursuit of personal growth and fulfillment.

Moreover, when formulating the main theoretical models of Quality of Life, authors have also followed Doyal and Gough’s theory of human needs [10]. Not only physical health but also individual autonomy are the basic human needs [2]. This theory makes it clear that the universality of its proposal does not imply ignorance of group differences, for example, the older adults. It argues that, in essence, the basic needs of this group are the same, but that the satisfactions they require may differ because they are subject, for example, to additional threats to their autonomy [11]. It is also reasonable to consider that human needs will be more easily achieved when there is good psychological well-being and an absence of emotional problems of anxiety and depression in people. Considering this model, we conducted the current study to analyze the Quality of life experienced by older adults and variables associated (psychological well-being, emotional distress and self-rated health).

Methods

This study was a cross-sectional survey. In order to enable more people to participate in the survey quickly and conveniently, we adopted snowball sampling and conducted anonymous online surveys through questionnaires. A well-qualified investigator in the research group in each university was responsible for questionnaires distribution and sample collection. They distributed the online survey and encouraged more people to see the questionnaires and participate in the survey. At the beginning of the survey, all respondents were provided with informed consent information to confirm their voluntary participation in the survey. The samples were collected from July 27, 2021 to July 31, 2022. The inclusion criteria for valid samples were: (1) Attending an university program for older adults from September 12, 2021 to December 30, 2022. (2) Age over or equal to 60 years. (3) The questionnaire information was basically completed without affecting data statistical analysis.

The sample size was calculated based on Cochran’s formula. The study involved 361 participants. Age ranged from 60 to 84 (M = 68.44, SD = 5.31), and 134 participants (37.1%) were men. Most participants were married or living with a partner (58.2%) and only 5% reported having bad perceived health. Snowball sampling technique was used in this study. Participants were recruited from three university programs for older adults at Universidad San Pablo-CEU de Madrid (Universitas Senioribus program), Universidad Pontificia de Salamanca (Experience’s University program) and Universidad Miguel Hernandez de Elche (SABIEX: Integral program for over 55 years old adults) (Spain). One university was located in the capital of Spain (CEU-Madrid), other university was located in the largest interior and rural region of Spain (Salamanca-Castilla y Leon) and the other university was located in the mediterranean coast (Elche-Comunidad Valenciana). Data were collected when older adults returned to in class activities after September 2021. Only four participants were removed because they did not specify their age. The study was approved by the University Ethics Committee. Informant consent was obtained from all participants.

The survey included some scales and questionnaires employed in the assessment of quality of life, sociodemographic characteristics, self-perceived health, psychological wellbeing (personal growth and purpose in life subscales) and emotional distress (anxiety and depression). In this research we have always used the global score of the questionnaires.

Quality of life (the dependent variable of this study) was assessed with the CASP-19 [2]. This 19-item scale was used to measure four domains of Quality of life: control, autonomy, self-realization and pleasure. Control describes the ability to actively intervene in their environment, autonomy represents freedom from unwanted interference from others. Self-realization describes the more introspective aspects of existence, whereas pleasure represents the enjoyment derived from the more dynamic (action-oriented) facets of life. Its design emphasized the exploration of positive and beneficial aspects of aging, departing from the traditional focus on medical and social care issues. It included 4-point Likert scale response options ranging from 0 (“never”) to 3 (“often”). A higher score indicates better Quality of life. In this research we have used the global score of the questionnaire The scale showed good reliability in our sample (Cronbach’s α = 0.86).

Sociodemographic factors measured included age and gender. Self-perceived health was assessed as the Spanish National Health Survey (Encuesta Nacional de Salud) measured the perceived health status. In other words, participants assessed their health status as very poor, poor, fair, good or very good.

Personal growth and purpose in life were assessed with two subscales of the Ryff’s Psychological Well-Being Scales [12]. Personal growth and purpose in life were measured by 7 and 6 items, respectively. Participants rated their responses on seven-point scales (1 = “never” to 7 = “always”). Ratings were summed with higher scores reflecting higher wellbeing. The scales showed adequate reliability for personal growth (Cronbach’s α = 0.73) and purpose in life (Cronbach’s α = 0.78) in our sample.

Anxiety and depressive symptoms were assessed with the fourteen-item Hospital Anxiety and Depression Scale [13]. Participants rated their symptoms during the last week on a four-point scale (0 to 3). Ratings were summed with higher scores reflecting increased anxiety and depression. Cronbach’s alpha was. The scale showed a good reliability for anxiety (Cronbach’s α = 0.82) and depression (Cronbach’s α = 0.75) in our sample.

Results

The mean CASP-19 score for the 361 participants who had going back to face-to-face classes was 39.02 (SD = 7.67). A stepwise regression analysis was used to explain the influence of proposed variables on older adults’ Quality of life, following the stress process model (Table 1). More purpose in life, personal growth, better self-perceived health and less anxiety and depression were significantly associated with greater level of Quality of life. Life purpose is the most relevant protective variable for Quality of life. The belief that one’s life is purposeful and meaningful is highly related with Quality of life.

Table 1.

Stepwise regression analysis of levels of quality of life

	β	Change in R2
Depression	− 0.306***	0.440
Purpose in life	0.348***	0.157
Health a	0.136***	0.019
Anxiety	− 0.173***	0.014
Personal growth	0.121**	0.008
Adjust R 2	0.632
F (5, 350)	124.57

^a High scores suggest best self-perceived health

** p < .01

*** p < .001

None of the sociodemographic variables were significant, but all emotional distress and psychological wellbeing variables were significantly associated with more Quality of life.

Discussion

Findings from this study stress that, overall, quality of life diminishes with, psychological ill-being and increases with psychological well-being. Lower psychological well-being (purpose and growth) and higher levels of ill-being (depression and anxiety) are significantly associated with worse quality of life, depression being the factor with highest relative importance, followed by purpose. The study also shows the effect of health. It also acknowledges that sociodemographic characteristics (i.e., sex and age) have no significant effect on quality of life when previous factors are considered.

Our primary finding corroborates the well-documented influence of depression on quality of life [5]. Older adults with higher depression scores do not possess the equivalent internal resources or the ability to adapt and adjust over time, as compared to individuals with lower scores. It is apparent that inadequate resources and coping mechanisms are correlated with the presence of depressive disorders or the severity of depressive symptoms in older adults. Therefore, it is not surprising that higher depression was related in our study with better Quality of life. It is of paramount importance for healthcare practitioners serving the older adults, along with healthcare administrators and strategists, to prioritize the management of depression in older individuals [4]. Moreover, depression is associated with higher social isolation and loneliness, which could lower patients’ Quality of life.

Additionally, our secondary finding underscores the significant role of anxiety, highlighting the necessity for increased attention to this condition. Given that prior research has established the impact of anxiety on quality of life [7], it is imperative to enhance efforts aimed at understanding and preventing anxiety in later life, whether at clinical or subclinical levels. This endeavor is essential for promoting healthier aging.

Quality of life implies a eudemonic perspective of well-being. It is associated to an individual sense of subjective life satisfaction [2]. Therefore, it is not surprising that purpose in life (the belief that one’s life is purposeful and meaningful) and personal growth (sense of continued growth and development as a person) were positively associated with Quality of life. Purpose in life and personal growth were linked to the eudemonic wellbeing, and therefore associated to Quality of life.

Moreover, the metrics of eudaimonic well-being have been empirically linked with subjective health outcomes in both cross-sectional and longitudinal research paradigms. The body of evidence further substantiates the role of eudaimonic well-being as a protective factor against health alterations correlated with the aging process. This form of well-being also exerts a positive impact on the status of diagnosed diseases or disabilities, with a specific emphasis on the element of purpose in life. Remarkably, individuals exhibiting higher levels of eudaimonic well-being demonstrated superior life expectancy, enhanced neuroendocrine regulation, improved inflammatory profiles, reduced cardiovascular risk factors, and more favorable sleep patterns [8]. Therefore, eudaimonic well-being could buffer against the adverse effects of low subjective health or worse physical health status on Quality of life.

A review has shown that major illness, poor physical functioning, high body mass index, etc. have a negative impact on Quality of life. Health and Quality of life tend to be correlated with each other. Health has been used as a proxy measure for Quality of life in many studies [11]. Success can refer to the attainment of personal goals of all types, including good health. Thus, it is not surprising that subjective health is a positive predictor of Quality of life in our research. Most older adults live out their lives in relatively good physical health. Nevertheless, a bad subjective health could be related with lower Quality of life in older adults.

Sociodemographic characteristics did not show any association with Quality of life and were not relevant. It is noteworthy that the present study did not identify an age-related effect on Quality of Life. Previous research has reported inconsistent findings regarding sex disparities in Quality of Life, with some studies indicating lower levels among men [14], others among women [15] and other studies showing no sex differences [16]. Regarding age, despite being an objective and sociodemographic variable with a relatively influence, the association between age and quality of life is intricate, as several studies show that quality of life and its domains vary between individuals and groups, and that a wide diversity of associated variables must be taken into consideration [17]. It is noteworthy that while aging is often associated with a decline in quality of life, this correlation may be spurious when additional variables are statistically controlled [11, 16]. Nevertheless, the lack of association for these sociodemographic factors in our study may be related to social and cultural aspects, which should be further researched [11].

There are some limitations to be acknowledged and addressed. First, because of the cross-sectional design, it is possible that the current results are not temporally stable for the older adults. It is important to analyze Quality of life responses across longitudinal studies as it is not feasible to accurately establish causal relationships in cross-sectional studies. Second, because of the modest sample size of the present study, we cannot be certain whether variables associated with Quality of life show all the Spanish cultural variations. Nevertheless, no evidence has emerged to support the hypothesis that certain Spanish cultural groups experienced Quality of life differently. The specific characteristics of older adults who attend university programs, such as their personality traits, intellectual capacity, and economic situation, constrain the generalizability of the results. Nevertheless, we have recruited populations from various socioeconomic regions of our country, including urban and rural areas, as well as coastal and inland regions. Third, these findings are limited to community-dwelling older-adults who attend university programs. This is a potential limitation to generalize the results of the present study to subjects living in long-term care facilities. Although only a minority of the older Spanish older adults was involved in university programs for older adults, more of them live in the community. Fourth, personal growth and purpose in life are two of the six psychological wellbeing variables described by Ryff. However, we included these two dimensions since they are key elements in psychological functioning and have been described previously as the main components of eudaimonia [18].

Despite these limitations, our results suggest that sociodemographic characteristics may not be as important for the older adults’ Quality of life as their levels of health, emotional distress and psychological wellbeing. Therefore, self-perceived health, anxiety, depression, personal growth and purpose in life had significant associations with Quality of life in older adults.

Conclusions

Although multiple studies have analyzed the role of health characteristics (such as perceived health) or depression, few have considered anxiety or some salutogenic characteristics (like purpose in life or personal growth) in the improve of Quality of Life. All these variables are connected with Quality of Life among older adults.

Because emotional distress affects Quality of life negatively it is important to detect emotional distress and treat distressed patients. Furthermore, psychological wellbeing and self-rated health affects Quality of life positively and detect psychological well-being. Therefore, it is important to detect and improve both. Thus, it is strongly advocated that healthcare professionals, both in specialized and primary care settings, adopt a bifocal treatment approach that encompasses considerations for both mental and physical health.

It is essential to develop perceived health and psychological wellbeing; and it is also necessary to buffer emotional distress to improve Quality of life among older adults. These results suggest that educational programs promoting perceived health, psychological wellbeing and emotional status may improve Quality of Life in older adults.

Abbreviations

CASP-19

Control, autonomy, pleasure, and self-realization Scale- 19 items

Author contributions

JL and GPR developed the study concept and design. JL had primary responsibility for the preparation of the manuscript. JL, ASC, ES and BB had primary responsibility for collecting the data. CN, ASC, ES and BB all provided input regarding the drafting and revising of the manuscript, critical review of the manuscript for important intellectual content, and approval of the final manuscript.

Funding

This work was funded by Spanish Ministry of Science and Innovation (PID2021-127986OB-I00)  MICIU/AEI /10.13039/501100011033 and FEDER, UE.

Data availability

The data that support the findings of this study are openly available in the Open Science Framework repository at https://osf.io/azx9j/.

Declarations

Conflict of interest

The authors have no competing interests to declare that are relevant to the content of this article.

Ethics approval and consent to participate

All methods were carried out in accordance with relevant guidelines and regulations. This survey was approved by the ethics panel of the Universidad San Pablo CEU (Reference 436/20/26). All participants in this study provided informed consent to participate.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.