Archives of Gerontology and Geriatrics 53 (2011) 278–283
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The relationship between physical, functional capacity and quality of life (QoL) among elderly people with a chronic disease ¨ ztu¨rk a, Tu¨lay Tarsuslu S¸ims¸ek a,*, Eylem Tu¨tu¨n Yu¨min a, Meral Sertel a, Murat Yu¨min b Asuman O a b
Abant Izzet Baysal University, School of Physical Therapy and Rehabilitation, Golkoy Campus, Go¨lko¨y, 14100 Bolu, Turkey Family Medicine, 14750 Seben, Bolu, Turkey
A R T I C L E I N F O
A B S T R A C T
Article history: Received 27 August 2010 Received in revised form 9 December 2010 Accepted 10 December 2010 Available online 7 January 2011
The aim of this study was to evaluate the relationship between physical and functional capacity and quality of life (QoL) among elderly people who have a chronic disease. The study included 100 elderly individuals aged 65 years and older, who have a chronic disease. The study examined the marital and educational status, social security status, kind of chronic disease, number of chronic diseases and whether participants use assistive devices for walking. The Nottingham health proﬁle (NHP) was used to evaluate QoL related to health; the physical mobility scale (PMS) was used to evaluate mobility in daily life and the functional independent measure (FIM) was used to evaluate functional independence in daily activities. In both female and male individuals, a statistically signiﬁcant difference was found between the number of chronic diseases, kind of chronic disease, educational status, marital status, total FIM, PMS and NHP values (p < 0.05). In males, there was a correlation between number of chronic illnesses and total NHP, FIM (p < 0.05), but in females, there were no correlation between number of chronic illnesses and total NHP, FIM (p > 0.05). There were no correlations between kind of chronic disease and PMS, NHP, FIM (p > 0.05) in either of genders. It was found that there are differences among elderly female and male individuals with a chronic disease in terms of the number of chronic diseases, types of chronic disease, mobility level, functional status and QoL; and mobility level is related to functional capacity and QoL in females. It is thought that the rehabilitation programs to improve physical and functional capacity in elderly people and applications that increase participation in activities and reduce pain may improve QoL. ß 2010 Elsevier Ireland Ltd. All rights reserved.
Keywords: Aging and chronic diseases Functional decline Quality of life
1. Introduction Old age is the last period of human life, which is unavoidable and irreversible, with unique biological, physiological, psychological and socio-economic features (Norris et al., 2008). During this period, elderly people encounter many health problems. Chronic and degenerative diseases, such as hypertension, osteoporosis, chronic obstructive pulmonary disease (COPD), and diabetes mellitus (DM) are the most frequently experienced health problems in old age (Fortin et al., 2006; Li et al., 2009). Health problems such as physical deﬁciencies, pain, cancer, cardiovascular diseases, dissatisfaction with life and social isolation are not speciﬁc to elderly people; however, they are among the most frequently experienced health problems in old age (Yoem et al., 2008). A higher number of chronic diseases are consistently associated with a higher prevalence of mobility limitations (Cornoni-Huntley et al., 1991; Kriesgman et al., 2004), and longitudinally with a higher incidence of mobility loss (Guralnik et al., 1993). Most previous studies have addressed cross-sectional associations * Corresponding author. Tel.: +90 374 254 1000; fax: +90 374 253 4663. E-mail address: [email protected]
(T.T. S¸ims¸ek). 0167-4943/$ – see front matter ß 2010 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.archger.2010.12.011
between the presence of speciﬁc chronic diseases and limitations in physical and functional status in elderly people (Peruzza et al., 2003; Ferrucci et al., 2004; Lee et al., 2006; Muszalik et al., 2009). It was found that various chronic diseases seen in elderly people affect physical and emotional dimensions of life, limit people’s daily activities and cause their QoL to decrease (Kempen et al., 1999; Wandell and Tovi, 2000; Johansson et al., 2004; Franzen et al., 2007; Carillo et al., 2009). The present study examined the relationship between physical, functional capacity and QoL among elderly people aged 65 or older who have a chronic disease. The second aim is to examine the relationship between socio-demographic factors and clinical factors (types of disease, number of diseases) in female and male elderly people. 2. Patients and methods The present study includes 100 individuals in total (43 females, 57 males) who live in Bolu province, Turkey, and who are 65 or older. The analyses were made using face-to-face interviews. The participants who were literate were asked to complete the questionnaire form; the researcher read the questions on the form
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and completed the answers given by the participants who had difﬁculty in reading or who were not literate. The individuals who were included within the study are consisted of individuals living in the province of Bolu, in their houses and patients who applied to the family medicine numbered 67. The criteria for inclusion in the study were voluntary participation, and being aged 65 or older, with a chronic disease. Individuals who do not have a chronic disease and who have a hearing or vision problem were excluded from the present study. The present study was approved by the Research Ethics Committe of the Faculty of Medicine, Abant Izzet Baysal University (2009/18). The study collected data on the individuals’ demographic characteristics, their marital and educational statuses, kind of chronic disease, number of chronic diseases, whether they receive social security and whether they use assistive devices for walking. The chronic diseases of individuals were obtained via questioning their diagnosis which had previously been made by a specialist physician. The chronic diseases which are questioned in individuals are given in Table 1. 2.1. Assessment tools The NHP was used to assess the health-related QoL, the PMS was used to assess mobility in daily life and the FIM was used to assess functional independence in daily activities.
The Turkish version of the NHP was used to assess the healthrelated QoL (Ku¨c¸u¨kdeveci et al., 2000). The NHP is a general QoL questionnaire, which measures perceived health problems and the extent to which these problems affect normal daily activities. The questionnaire is comprised of 38 items and evaluates six dimensions of the health statuses of individuals: energy (3 items), pain (8 items), emotional reactions (9 items), sleep (5 items), social isolation (5 items) and physical activity (8 items). The questions require yes/no answers. Each section is scored between 0 and 100, where 0 represents the best health status and 100 represent the worst health status. The PMS is a valid and reliable test developed by Australian physiotherapists. This scale evaluates the speciﬁc mobility activities necessary for independently performing life functions (Nitz and Hourigan, 2006). There are 7 parameters in the PMS in total, and each parameter is scored on a ﬁve-point scale. The lowest score in the PMS is 0; the highest score is 40. A higher score indicates that the mobility of the related individual is not limited. The Turkish version of the FIM was used to evaluate functional independence in daily activities (Kenneth, 1990; Ku¨c¸u¨kdeveci et al., 2002). The FIM analyzes the two different aspects of impairment, namely motor and cognitive functions. The scale consists of 6 functional sections; self care, sphincter control, mobility, locomotion, communication and social perception. In the FIM, 18 activities are evaluated in terms of functional independence using a 7-point scale. The highest possible score is 126. The
Table 1 The socio-demographic data of the participants mean S.D. or n(%).
72.55 6.48 157.51 7.25 70.95 10.25
73.29 6.3 169.38 6.61 76.07 12.12
0.570 8.523 2.230
>0.05 <0.05 <0.05
28.67 4.33 8(18.6) – 35(81.4) 43 (100)
26.55 4.34 18(31.57) 1 (1.75) 38(66.66) 57(100)
Kind of chronic disorders Respiratory Musculoskeletal Cardiovascular Diabetes Urinary or bowel problems Systemic problems
13(30.2) 20(46.5) 8(18.6) 1(2.3) 1(2.3)
5 (8.77) 9(15.78) 28(49.12) 7(12.28) 6(10.52) 2(3.5)
Number of chronic illnesses 1 2 3 4
18(41.8) 17(39.5) 7(16.2) 1(2.3)
37(64.91) 16(28.07) 1(1.75) 3(5.25)
Marital status Married Single Widowed Divorced
17(39.53) – 26(60.47) –
41(71.92) 4(7.01) 11(19.29) 1(1.75)
20(46.5) 20(46.5) 1(2.3) 2(4.6) –
10(17.54) 33(57.89) 6(10.52) 3(5.26) 4(7.01) 1(1.75)
Social security Yes No
Use of assistive devices Yes No
Age (year) Height (cm) Weight (kg) BMI (kg/m2) Total Normal Underweight Overweight
Educational level Illiterate Primary school Secondary school High school College Master degree
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Table 2 The differences between physical mobility, HRQoL and functional levels according to gender in elderly, mean S.D.
high score obtained from FIM shows the independence of the individual in daily life activities. 2.2. Statistical analysis
PMS NHPEL NHPP NHPER NHPSI NHPS NHPPA NHP total FIM total
The SPSS statistical package (version 11.0 for Windows) was used to analyze the obtained data. Mean S.D. were used in descriptive statistics. In the statistical analysis, the t-test and the x2test were used to determine the differences between sociodemographic characteristics; the t-test was used to determine differences between physical, functional level and QoL; and Pearson’s correlation analysis was used to determine the relationship between the evaluation parameters. The level of signiﬁcance was accepted as p < 0.05.
38.2 3.27 45.42 37.06 40.05 33.88 29.11 30.98 25.77 32.47 28.84 27.23 30.77 23.77 199.38 148.36 122.32 107
39.87 0.5 24.97 30.97 16.32 26.68 9.81 15.66 9.3 20.39 16.95 19.89 10.96 12.21 89.03 89.73 125.45 1.6
p 3.789 2.972 3.878 4.03 3.073 2.50 5.368 4.566 2.178
0.000** 0.003** 0.000** 0.000** 0.002** 0.014* 0.000** 0.000** 0.031*
Abbreviations: NHPLE, NHPL level of energy; NHPP, NHP pain; NHPER, NHP emotional reaction; NHPSI, NHP social isolation; NHPS, NHP sleep; NHPPA, NHP physical activity. * p < 0.05, t-test. ** p < 0.01, t-test.
Of the individuals included in the study, 43 (43%) were female, 57 (57%) were male. The socio-demographic data of the participants are given in Table 1. It was found that cardiovascular diseases are more common among males than females. The other most common health problems among women are skeletal system-related problems, diabetes, urinary or bowel problems and systemic problems; in
men, the other most common health problems are musculoskeletal problems, diabetes, urinary and bowel problems, respiratory and systemic problems. While more than one chronic disease is common in women, it is more common for men to have only 1 chronic disease (p < 0.05). Statistically signiﬁcant differences were found between men and women in terms of educational status,
Table 3 The correlations between HRQoL, physical mobility and functional level according to gender in elderly people. Age
Females Males Age
No. of chr. dis.
Kind chr. dis.
Education r 0.046 1 p 0.729 Marital status r 0.174 0.15 p 0.193 0.262 PMS r 0.106 0.0317 p 0.428 0.814 NHPEL r 0.084 0.071 p 0.533 0.597 NHPP r 0.266* 0.01 p 0.045 0.937 NHPER r 0.1 0.146 p 0.46 0.28 NHPSI r 0.017 0.074 p 0.897 0.584 NHPS r 0.268* 0.204 p 0.045 0.129 NHPPA r 0.006 0.332* p 0.959 0.012 NHP total r 0.094 0.077 p 0.489 0.571 FIM total r 0.084 0.226 p 0.538 0.093 Number of chronic illnesses r 0.106 0.248 p 0.435 0.065 Kind of chronic disease r 0.335* 0.185 p 0.01 0.166 * **
p < 0.05. p < 0.01.
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civil status, use of assistive devices for walking in daily life and reliance on social security (p < 0.05). A statistically signiﬁcant difference was found between the PMS, FIM, NHP total values and all the sub-items of the NHP in males and females (p < 0.05) (Table 2). In the correlation analysis of female participants, a relationship was found between age and NHP energy level, age and NHP physical activity items (p < 0.05). Similarly, a relationship was found between the PMS and energy level, pain, physical activity items and total NHP; and between the PMS and total FIM (p < 0.05). A relationship was found between total FIM and energy level, pain and physical activity items and between kind of diseases and the physical activity item of the NHP (p < 0.05). However, no relationship was found between the number of chronic diseases, age, educational status, marital status, total FIM, PMS and NHP (p > 0.05), and between kind of chronic diseases, age, educational status, marital status, total FIM, PMS and NHP (p > 0.05) (Table 3). In the correlation analysis of male participants, a relationship was found between age, kind of disease, sleep and pain items (p < 0.05). Similarly, a relationship was found between educational status and level of physical activity, and between number of chronic diseases, marital status, emotional reactions, social isolation, sleep, physical activity and total NHP (p < 0.05). In men, a relationship was found between the number of chronic diseases and total FIM, and between total FIM and emotional reactions, social isolation, sleep, pain, physical activity (p < 0.05). However, no relationship was found between kind of disease and educational status, PMS, NHP and FIM (p < 0.05). Similarly, no relationship was found between the number of diseases and age, educational status, marital status and PMS (p < 0.05) (Table 3). 4. Discussion The average age of the individuals included in the present study is in the category of the younger olds, and the average age of men is higher than that of women. The level of education is lower in women; and the rate of overweight individuals and the rate of use of assistive devices for walking in daily life are higher in women. These results of the present study are similar to those of previous studies in the literature (Birtane et al., 2000; C¸ivi and Tanrikulu, ¨ zdemir et al., 2005). Kempen 2000; Van Jaarsveld et al., 2002; O et al. (1999) found that there was a relationship between level of education and the physical, social function and mental health parameters of QoL in elderly people. It was reported that being overweight and obesity increase the rate of chronic problems in elderly people (Salihu et al., 2009), while reducing the level of daily life activities and QoL (Arterburn et al., 2004). In the present study, women were have more than one chronic disease and more likely to be overweight and to have lower QoL. The NHP is a well-established, generic health-related QoL measure that has also been proven to be useful for elderly people (Orﬁla et al., 2006). In the present study, the NHP was used to evaluate QoL. In the present study, in parallel to the study by Orﬁla et al. (2006), it was found that women scored much lower than men in all the dimensions of NHP and total NHP in the healthrelated QoL evaluations. While cardiovascular and musculoskeletal problems are more common in women, cardiovascular problems are more common in men. It was also found that the other most common problems in women are the skeletal system-related problems, DM, urinary or bowel problems and systemic problems; in men, the most common problems are musculoskeletal problems, DM, urinary and bowel problems, respiratory and systemic problems. While it is common for women to have more than one chronic disease, it is more common for men to have only one chronic disease. It is thought that these results are among the reasons why total NHP
and the dimensions of NHP are lower in women compared to men. In addition, it is thought that the severity of the disease and sociodemographic differences (BMI, level of education, marital status, reliance on social security) might be related to lower QoL in women. In related studies, it is reported that the rate of cardiovascular diseases is higher in men (Sytkowski et al., 1996), and the combination of osteo-muscular problems (Kempen et al., 1997), DM (Wandell and Tovi, 2000), COPD (Peruzza et al., ¨ zdemir 2003; Talley and Wicks, 2009), cardiovascular diseases (O et al., 2005) arthritis, back problems (Orﬁla et al., 2006), and many ¨ zdemir et al., 2005) cause reduced QoL other chronic diseases (O among elderly people. In studies by Peruzza et al. (2003) and Talley and Wicks (2009) it was reported that the low QoL in elderly people with COPD might be related to the severity of the disease. The mostly affected QoL parameters in women with a chronic disease are level of energy, pain and physical activity items; while in men they are level of energy, sleep and pain items. It is thought that the affected QoL parameters in both groups are related to the current chronic diseases. It is thought that the sleep problems in men result from respiratory disorders (especially at night) due to cardiovascular problems (Hu and Meek, 2005; Talley and Wicks, 2009). The musculoskeletal problems in women might cause greater physical activity disorders (especially walking) compared to men (Orﬁla et al., 2006). Hence, the level of physical mobility of men (PMS) was found to be higher than that of women. Chronic problems in elderly people also affect physical and functional capacity (Markides et al., 1996; Agu¨ero et al., 2002; Peruzza et al., 2003; Kriesgman et al., 2004). In the study by Kriesgman et al. (2004), a strong relationship was found between the number of chronic diseases except for the determined 7 diseases in elderly people (COPD, cardiac diseases, peripheral atherosclerosis, stroke, DM, arthritis and malignancies) and physical functional decline. In the present study, no relationship was found between the number of chronic diseases and the PMS, FIM, kind of disease and the PMS, FIM in both genders. However, a relationship was found between kind of disease and the physical activity item of the NHP in women. It is thought that this results from the difference between the distributions of chronic diseases in men and women and from the severity of diseases. No relationship was found in the PMS, while a relationship was found with the physical activity parameter of the NHP. Another reason for this might be the differing evaluation methods used in various studies. In the present study, it was found that chronic problems in elderly people do not affect the level of physical mobility; however, they affect the level of physical activity in elderly women. No relationship was found between the FIM and the NHP in women, while a relationship was found between these scales in men. Although HRQoL and functional capacity may be correlated, they are not synonymous, and represent different components of health status (Masoudi et al., 2004). Functional status is deﬁned as one’s ability to perform speciﬁc activities without any physical or symptomatic limitation. In contrast, HRQoL reﬂects the discrepancy between a patient’s current function and their expected health state (Carr et al., 2001; Masoudi et al., 2004). It is thought that the reason why a relationship was found between the FIM and the NHP in women but not men is that there may be a difference in the variations of disease, differences in the health statuses of the individuals and their effects on functional status. More comprehensive studies are required on this subject. Among older adults, impaired mobility is associated with a loss of independence, reduced QoL, institutionalization and higher risk of mortality (Hirvensalo, 2000; Rubinstein et al., 2001; Agu¨ero et al., 2002; Netuveli et al., 2006; Orﬁla et al., 2006; Von Bonsdorff et al., 2006). Dirik et al. (2006) found a statistically signiﬁcant difference between men and women in terms of the level of mobility; women have more limitations compared to men and
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their performance of daily activities is affected. In parallel to previous studies, the present study found that the mobility levels of women are lower than those of men and the level of mobility in women is related to functional status in daily activities. While no relationship was found in men between the mobility level and total NHP and any of the related parameters, a relationship was found in women between mobility and QoL, and between mobility and level of energy, pain, and physical activity items. In women, the level of mobility may affect QoL in terms of activity participation, especially due to the increased pain during activities. Chronic statuses such as arthritis and osteoporosis may especially affect performance and level of energy with an activity and may cause pain; this may cause reduced QoL. The present study has several limitations, one of which is that elderly people have different chronic diseases. However, the clinical diagnoses of the individuals are not considered because the primary criterion for being included in the present study is being an elderly person with a chronic disease. The most common chronic diseases among participants in the present study are cardiovascular, musculo-skeletal diseases and diabetes; the number of those who have a urinary and bowel problems or a respiratory and systemic problem is lower. Therefore, it was not possible to produce separate statistics for each disease. The effect of chronic diseases on functional capacity and QoL in elderly people can be examined in more detail in other studies selecting a speciﬁc disease group. The second limitation is that severity of disease was not investigated, as it is not among the basic aims of the present study. However, the effect of the severity of a disease on functional, physical capacity and QoL can be examined by questioning the factor of severity of disease in elderly people with a chronic disease. The third, on the other hand, was the inadequacy of the number of individuals who were included in the study. The inadequacy of the number of individuals does not allow many complex multivariate analyses. Increasing the number of individuals, it is necessary to perform more studies concerning the subject. 5. Conclusions In the present study, it was found that there are statistically signiﬁcant differences between elderly male and female individuals with a chronic disease in terms of kind of disease, number of diseases, level of mobility, functional status and QoL; these differences also affect women in terms of QoL and level of daily life activities. It is thought that, in elderly people with a chronic disease, especially in women, rehabilitation programs to improve physical and functional capacity, exercises which increase the level of physical activity and energy and approaches directed to reduce pain will play an important role in improving QoL. Conﬂict of interest statement None. References Agu¨ero, T., Von Strauss, E., Viitanen, M., Winblad, B., Fratiglioni, L., 2002. Institutionalization in the elderly: the role of chronic diseases and dementia. Crosssectional and longitudinal data from a population-based study. J. Clin. Epidemiol. 54, 795–801. Arterburn, D., Crane, P., Sullivan, S., 2004. The coming epidemic of obesity in elderly Americans. J. Am. Geriatr. Soc. 52, 1907–1912. Birtane, M., Tuna, H., Ekuklu, G., Uzunca, K., Akc¸i, C., Kokino, S., 2000. The evaluation of factors effecting quality of life in the residents of Edirne elderly instution. Geriatrics 3, 141–145. Carillo, K.G., Pena, G.C., Mudgal, J., Romero, X., Arenas, L.D., Salmeron, J., 2009. Role of depressive symptoms and comorbid chronic disease on health-related quality of life among community-dwelling older adults. J. Psychosom. Res. 66, 127–135.
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