Health Related Quality of Life among older adults: Zooming into its complex and dynamic development
“How do you feel today?” Maybe this question seems very easy to answer, and maybe the majority of the readers of this blog post would answer “I’m feeling good! No problem at all!”. But what does this question really mean? What information do we actually take into account when we answer a simple question as this one? One’s emotions? One’s health? One’s current social environment? And why it is important to assess and analyze this information? In order to answer such questions, we have to make a step backward and define the concept of health and Health Related Quality of Life (HRQOL), as well as its use in contemporary society.
Health and Health Related Quality of Life
The World Health Organization defined health (1946) as a “complete state of physical, mental and social well-being and not merely the absence of disease or infirmity’’. Hence, health is multidimensional. Moreover, it is not a “dichotomous” construct (health VS disease), but its quality can range along a continuous scale (from poor to excellent). Accordingly, HRQOL refers to physical, mental, and social domains of health that are seen as distinct areas, which are influenced by a person’s experiences, beliefs, expectations, and perceptions (Testa & Simonson, 1996). HRQOL narrows the focus to the effects of health, illness, and treatment on Quality of Life (QOL), and excludes aspects of QOL that are not related to health, such as cultural, political, or societal attributes (Ferrans, Zerwic, Wilbur, & Larson, 2005). In line with these defining properties, in my dissertation I defined the HRQOL as a complex, dynamic, multidimensional, and individual construct, which emerges from interactions among the health domains (physical, mental and social health), random influences (e.g., life events), adaptability to life events (ability to cope with stressors) and individual characteristics (e.g., age, presence of diseases, lifestyle habits) (Roppolo et al., 2015). According to this definition, answering the question “how do you feel today?” may not be so easy to answer after all….
Studying the developmental process of HRQOL
HRQOL is person-centered measure that allows one to predict negative health outcomes by measuring the impact of different interventions (e.g., drug therapy) on the self-perceptions of health. Classically, the health status of a society was indicated by indicators of mortality and morbidity. But, the HRQOL provides more information about the perceived health status of individuals and populations, which is important in our aging society. However, we know relatively little about the development of HRQOL during the ageing process. We know how HRQOL generally behaves over the long run, before and after particular kinds of events. For instance, several chronic diseases tend to negatively affect all the HRQOL components. Yet, we do not know how such trends emerge on a shorter time-scale: For instance, if after negative events the general decreasing trajectory proceeds with linear trend or if it shows also increasing steps, sudden jumps, etc. Focusing on the latter is crucial, because it may give new insights about the developmental process of HRQOL during life, thereby marking risk phases that allow a more precise and efficient way to apply interventions. To study such (short-term) developments of HRQOL, one needs to apply a Dynamic Systems approach. This approach is focused on processes of change and developmental patterns across time (Kunnen, 2012). Specifically, the changes of HRQOL measured on a daily basis (variability) could serve as a predictor of ageing-related negative health outcomes (cf. van Geert & van Dijk, 2002).
“a period of increased variability may signal a period of increased risk”
In our own study (Roppolo, 2015), we analyzed data collected on 100 consecutive days of HRQOL among 22 institutionalized Italian older adults. Daily data were assessed in this sample with the use of a short and easy diary-based questionnaire. Results showed that before a “perturbation” (e.g., fall, hospitalization), day-to-day changes of HRQOL were higher compared to changes of that individual after the perturbation. The increase in day-to-day changes may thus be a sort of indicator of temporary instability that may modify, or compromise, the developmental trend. More specifically, a period of increased variability may signal a period of increased risk. Moreover, higher daily fluctuations of HRQOL were negatively related to the long-term health trends (measured on a monthly basis). In fact, we found that participants who had very different responses on a daily basis (e.g., one day a relatively high level of HRQOL and the next day a relatively low level) were ultimately the worst off in terms of their HRQOL and disability. These results strongly suggest that relatively high day-to-day changes are related to the negative development of health outcomes in institutionalized older adults.
In my PhD research, we proposed that HRQOL may be seen and conceptualized as a dynamic construct, which emerges from complex interactions among the health domains, random influences, individual characteristics and adaptability to life events. Moreover, in studying the ageing process the Dynamic Systems approach is very suitable for the study of short-term changes (e.g., day-to-day) of HRQOL in order to predict, and prevent negative health outcomes. In this view, high day-to-day changes (variability) of HRQOL may be seen as a warning signal for the development of negative trends and perturbations in HRQOL.
Ferrans, C. E., Zerwic, J. J., Wilbur, J. E., & Larson, J. L. (2005). Conceptual Model of Health-Related Quality of Life. Journal of Nursing Scholarship, 37, 336–342. doi:10.1111/j.1547-5069.2005.00058.x
Kunnen, S. E. (2012). A Dynamic Systems Approach of Adolescent Development. Psychology Press.
Roppolo, M. (2015). How do you feel today?: The use of a Dynamic Systems approach in the conceptualization and analysis of Health Related Quality of Life in the older adults [Groningen]: University of Groningen. ISBN: 978-90-367-8237-1.
Roppolo, M., Kunnen, S., Mulasso, A., Rabaglietti, E., & Van Geert, P. (2015). Older adults and Health Related Quality of Life: a conceptual model based on dynamic systems. (In Press: Wolfe R, ed. Psychological Health and Needs Research Developments. Vol I. Psychology. Hauppauge NY: Nova Science Publishers; 2015. ISBN: 978-1-63483-332-5).
Testa, M. A., & Simonson, D. C. (1996). Assessment of Quality-of-Life Outcomes. New England Journal of Medicine, 334, 835–840. doi:10.1056/NEJM199603283341306
Van Geert, P., & van Dijk, M. (2002). Focus on variability: New tools to study intra-individual variability in developmental data. Infant Behavior and Development, 25, 340–374. doi:10.1016/S0163-6383(02)00140-6