Early-life socioeconomic circumstances explain quality of life differences in old age, but not their evolution over ageing

Hedonic and eudemonic well-being

Quality of life is an umbrella term that includes desirable outcomes such as well-being, both in its objective and its subjective dimensions. Objective appraisal is usually measured with indicators such as income, education, health, living area, etc. When entering into the subjective appraisal of well-being, there are two main approaches, namely the hedonic and the eudaimonic ones. Most of the followers of the former type of tradition agree with the steps suggested by Jeremy Bentham and care about “feeling good” whereas the followers of the latter usually tap into the heritage of Aristotle and aim for a “good life”, or the realization of the self. There are multiple measures for both approaches. Life satisfaction measured on a 0-10 scale gathers a wide consensus to measure hedonic well-being whereas eudaimonic measures are much more numerous and scattered. This is partly due to the inherent complexity of the construct and its multidimensionality (autonomy, self-acceptance, environmental mastery, life purpose…). Among the scales developed to assess eudaimonic well-being, one can cite Psychological Well-being (PWB) Scale or the Subjective vitality scale. A scale entitled CASP[1] 19 was used to assess both the eudaimonic and hedonic dimensions of well-being. Moreover, unlike the other scales that are mainly used in the general population, CASP is specifically adapted to assess well-being in the elderly population.

Figure 1. Diagram of the objective and subjective dimensions and measures of quality of life

Early-life socioeconomic circumstances as a predictor of quality of life

The origins of poor quality of life may stem from early-life risk factors, such early-life socioeconomic circumstances (SEC). Studies consistently showed that individuals who experienced poor SEC during childhood had lower levels of health functioning in older age, including physical, mental and social dimensions of health. The picture is blurrier as far as well-being is concerned. Some studies suggest that early-life SEC, social mobility, as well as other measures of opportunity (gender, ethnicity) affect the hedonic well-being of adults, whereas others studies revealed no or small effects.

Various factors may explain previous inconsistencies in the literature. First, studies mainly rely on a unidimensional measure of early-life SEC (for example, focused only on father’s occupational position) or combined different dimensions of early-life SEC into a single score (for example, mixed together material and cultural aspects of socioeconomic disadvantage). Second, very few studies have assessed whether the associations between early-life SEC and well-being are independent from other early-life events likely to co-occur, such as adverse childhood experiences or childhood health problems. Third, when the data were longitudinal, the statistical approach used was not particularly suited to accurately estimate change over ageing.

Therefore, to fill this knowledge gap, the current study aims to determine whether individuals who experienced poor early-life SEC showed lower level of well-being in older age and a steeper rate of well-being decline over ageing.

We used data on more than 23,000 adults in older age from the survey of health, Ageing, and Retirement in Europe (SHARE), a 12-year large-scale longitudinal study with repeated measurement of health indicators of the same participants over time (2004-2015, assessments every 2 years). Number of books at home (0-10 vs. more books at home), overcrowding (more vs. less than one person per room in the household), occupational position of the household’s main breadwinner (first and second vs. higher skills levels of the International Standard Classification of Occupations), and housing quality (absence vs. presence of either fixed bath, cold running water supply, hot running water supply, inside toilet, or central heating) were used as indicators of early-life SEC. A short version (12 items) of the CASP-19 scale was used to assess well-being.

Figure 2. The four dimensions of early-life socioeconomic circumstances

Number of books at home during childhood and well-being

Our results showed that early-life SEC were associated with the level of well-being in both men and women. Specifically, in men, a low number of books at home, a low occupational position of the main breadwinner, and a low housing quality were associated with a lower level of well-being. In women, only a low number of books at home was associated with well-being. The critical role of number for books was confirmed by results obtained from other health-related outcomes (muscle strength, peak expiratory flow, delayed recall, verbal fluency, and depression) showing that this cultural aspect of disadvantage has a wide influence that affect all the dimensions of health. By contrast, our results showed that men and women living in poor early-life SEC (all these indicators) did not experienced stepper decline rate of well-being decline over ageing.

From this study, we can conclude that early-life SEC, especially a cultural aspect of disadvantage (i.e., the numbers of book at home), are associated with the level of well-being in both men and women. Theoretically, this result provides support for the long-lasting influence of early-life SEC on health in older age. By contrast, we did not find evidence of the contribution of these early-life exposures to differences in trajectories of well-being over ageing.  Such inconsistency (between level and trajectories) could contribute to shedding light on other critical predictors of healthy ageing trajectories.

Guest blog by Cheval Boris, Gaël Brulé and Stéphane Cullati.

Cheval, B., Orsholits, D., Sieber, S., Stringhini, S., Courvoisier, D., Kliegel, M., Boisgontier, M.P. and Cullati, S., 2019. Early-life socioeconomic circumstances explain health differences in old age, but not their evolution over time. J Epidemiol Community Health, pp.jech-2019. http://dx.doi.org/10.1136/jech-2019-212110

[1] Control, Autonomy, and Self-realization

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The impact of a cancer diagnosis on health and wellbeing

People with cancer are living longer than ever before. Developments in the detection and treatment of cancer mean that half of people diagnosed with cancer in the UK survive for at least 10 years after the point of diagnosis. As such, there is now a growing emphasis not only on prolonging life, but enhancing quality of life for these patients.

Emerging evidence suggests that cancer survivors may suffer impairments in health and wellbeing that pre-date their cancer diagnosis by several years. In one of the first studies to include pre-diagnostic data in analyses of changes in health and wellbeing around the time of a cancer diagnosis, we observed differences in self-rated health, physical function, quality of life, and psychological wellbeing between cancer cases and controls at all examined time points – including up to 2 years before the cancer was diagnosed. This finding begs the question: How far in advance of a cancer diagnosis do impairments in health and wellbeing become evident?

Using prospective data from a large, population-based cohort, we examined changes in a range of health and wellbeing outcomes at two-year intervals from 4-6 years pre-cancer diagnosis to 0-2 years post-diagnosis. We included data from a cancer-free comparison group to distinguish changes in cancer survivors from those occurring in the general population.

Our results indicate that there may be early signs of deterioration in perceptions of health that precede the development of symptoms leading to diagnosis by many years; potential targets for new thinking about cancer awareness and early diagnosis. Some deficits (e.g. relating to mobility and disability) may be of long standing, evident up to six years prior to diagnosis. Other changes (e.g. in depression and quality of life) appear to be more acute in nature and may require targeted support around the point of diagnosis.

Focusing in on quality of life (Figure 1), operationalised as total CASP-19 score, it is clear to see that while scores were almost identical in both groups at 2-4 and 0-2 years pre-diagnosis, from 0-2 years pre-diagnosis to 0-2 years post-diagnosis, mean quality of life decline in the cancer survivor group and increased slightly in the comparison group.

Figure 1_Quality of life by group and time

Figure 1. Quality of life by group and time. The mean quality life score (with 95% confidence intervals) for each group at each time point (adjusted for age, sex, wealth, and diagnosis wave) is shown. ** P < 0.01 for the difference between the cancer survivor group and comparison group.

 These findings have important implications for clinical practice. Health problems that predate the cancer diagnosis by a number of years may contribute to the onset of cancer or share a common aetiology. With potentially modifiable risk factors such as obesity, physical activity, diet, smoking, and alcohol intake among the leading causes of cancer death, health promotion and behaviour change interventions at the general-population level continue to be of critical importance.

More acute changes in depression and quality of life that take place around the time of diagnosis are likely a reaction to the stressful nature of cancer diagnosis and treatment. This highlights a need to ensure cancer patients are screened for these risk factors at diagnosis and have access to psychological support. With evidence relating psychosocial stress to adverse changes in the cellular immune response at the tumor level, which may lead to faster disease progression, initiatives aimed at reducing stress and enhancing quality of life may even offer significant benefits in terms of disease course.

The next steps for advancing this research are to establish whether similar trends are observed in patient subgroups, such as men and women, those from higher versus lower SES levels, those affected by cancer at various sites/organs, and those diagnosed at different stages.

Guest blog post by Dr Sarah E. Jackson, Department of Behavioural Science and Health, University College London.

This article is based on:

Jackson SE, Williams K, Beeken RJ, Steptoe A. Changes in health and wellbeing in the years leading up to a cancer diagnosis: a prospective cohort study. Cancer Prevention Research. 2019; 12(2): 79-87. DOI: 10.1158/1940-6207.CAPR-18-0277

Long-term trajectories of depressive symptoms in old age: relationships with sociodemographic and health-related factors

Depression is more than feeling blue and transitorily losing the capacity to experience pleasure. Depression syndromes are highly prevalent in later life, and last longer than in other periods of life. Almost one in three older people may show clinical levels of depressive symptoms in the UK. Clinically relevant depression symptom episodes in old age are related to devastating consequences (e.g., increased risk of mortality, higher disability, reduced quality of life), even from earliest stages (e.g., subclinical conditions). Little is known about the relationship between symptom course and health-related outcomes. The search for person-specific symptom trajectories may help identify at-risk profiles, thus uncovering potential targets for treatment.

Many factors deserve consideration when depression course being studied. Sex constitutes a biological condition highly connected with depression symptom manifestation. Why do women fall into depression more frequently than men? Probably this is due to sexually-mediated biological processes (e.g., estradiol releasing patterns) and social influence that may put women at higher risk for developing depression problems. Moreover, women often show more heightened courses of depression symptoms over time. Unfortunately, little is known about the sex-specific trajectories of depression symptoms and their related impact on daily living, health and quality of life.

This study aimed at depicting the longitudinal trajectories of depression symptoms in older men and women, with a special interest in identifying heterogeneous trajectories of symptoms. Moreover, we intended to uncover the sociodemographic and health-related profile that featured each symptom trajectory. Finally, we were interested in examining how symptom trajectories may predict health-related outcomes two years later (i.e., quality of life, satisfaction with life and daily living functioning).

To do so, we used data from the English Longitudinal Study of Ageing (ELSA). The ELSA constitutes an excellent cohort study on ageing, relied on surveying British older adults every two years since 2002. The study aims at collecting information across multiple domains (socioeconomic, environmental, health-related, etc.). More concretely, data from 8317 older adults (46.02% men), aged between 65-90 years, were used in our study. None of these participants showed dementia diagnosis and responded by themselves the ELSA survey across waves.

Depressive symptoms were assessed over an 8-year follow-up (from 2002-2010, across five waves), by means of the Center for Epidemiologic Studies Depression Scale, 8-item version (CES-D 8). Moreover, information on time-varying (self-reported health across waves, amount of morbid conditions, feelings of loneliness, sensory function course) and time invariant depression concomitants (education level, household income, history of psychiatric problems in adulthood and age of retirement) were collected.

The identification of sex-specific symptom trajectories relied on robust structural equation modelling. Also, the relationships between symptom trajectory membership and concomitants were examined. Finally, generalised linear regression was used to examine how symptom trajectory membership may predict health-related outcomes at wave 6 (2012). The CASP-19 (the composite score) was used to measure quality of life. The instrument works quite well in old population and shows adequate psychometric properties. More concretely, we found satisfactory reliability levels within our sample (Cronbach’s α = .89).

As a result, we uncovered three heterogeneous trajectories of depression symptoms in men and women. For both sexes, we identified a low-symptom trajectory class (covering more than 77% of men and 68% of women, respectively), with minimal symptom levels over time; a subclinical-symptom trajectory (over 17% of men and 21% of women, respectively), featured by increasing levels of symptoms, that surpassed the cut-off point of clinical meaningfulness over time; and a chronic-symptom trajectory (6% of men and 11% of women), featured by heightened levels of symptoms over time. Sex-related differences were revealed in terms of higher proportion of women showing subclinical and chronic-symptom trajectories in comparison to men. For both sexes, the chronic-symptom trajectory was associated with increasing course of hearing difficulties and the history of psychiatric problems. The subclinical-symptom trajectory was featured by a higher increase in visual difficulties over time. Also, some sex-specific relationships were found: higher amount of morbid conditions in women with subclinical-symptom trajectory; and higher multimorbidity and loneliness feelings in men with chronic-symptom trajectory.

Finally, trajectory class predicted the health-related outcomes in the follow-up. More concretely, individuals with a chronic-symptom trajectory showed the lowest levels of quality of life and satisfaction with life, and the highest levels of disability. Surprisingly, individuals showing a subclinical-symptom trajectory also manifested poorer health-related outcomes than individuals in the normative trajectory class.

Our study constitutes a flexible, but robust approach to study depression symptom dynamics over time and its concomitants. We aimed at providing some evidence to raise awareness of personalised medicine (by means of identifying person-specific trajectories) and its usefulness in geriatric sciences. Moreover, we would like to highlight that depression should be tackled even from its earliest states (subclinical symptom trajectories also showed decreased quality of life) in order to tackle its devastating impact.

Manuscript published in: De la Torre-luque A, De la Fuente J, Prina M, Sanchez-Niubo A, Haro JM, Ayuso-Mateos JL. Long-term trajectories of depressive symptoms in old age: Relationships with sociodemographic and health-related factors. J Affect Disord. 2019;246(November 2018):329-337. doi:10.1016/j.jad.2018.12.122

Guest blog by Alejandro de la Torre Luque, Centre for Biomedical Research in Mental Health (CIBERSAM), Department of Psychiatry. Universidad Autonoma de Madrid, Spain: alejandro.delatorre@uam.es

Providing care to ageing parents: Is it damaging for quality of life?

Next to spouses and partners, adult children are the most important source of support for older persons in need of care. When adult children take on the caregiver role, this may not be without negative consequences, however. In a recent study published in Ageing and Society, Emily Grundy and I used the short version of the CASP-scale to examine how adult children’s quality of life changes when they start providing informal care to ageing parents.

The team that designed the CASP-scale defined quality of life as “the degree to which human needs are satisfied”. They argued that to achieve quality of life there were four key domains of need to be satisfied: control, autonomy, self-realization and pleasure. It is important to note that caregiving can bring positive things for the person providing it, such as learning new skills or a heightened sense of purpose. Nevertheless, we expected the overall impact of caregiving on quality of life to be negative, because the caregiver-stress model developed by Leonard Pearlin and colleagues suggests that caregiving can be detrimental for all of the four domains of quality of life.

Particularly when the needs of person care for are high, caregiving may diminish one’s sense of mastery, that is, the perceived control over forces that influence one’s life.

Moreover, caregivers may experience role captivity, that is, the feeling of being in the caregiving role involuntarily. This experience is at odds with a sense of autonomy.

Furthermore, caregiving may be a barrier for self-realization, given that Pearlin and colleagues explain that the identity and the life of a caregiver often becomes closely bound to those of the person cared for. For the caregiver, this may result in loss of self. The stress that results both directly and indirectly from caregiving can impede the pleasure experienced by persons providing care.

The caregiver stress model also stresses the importance of the context in which care is provided. When governments make care services more easily accessible, adult children of older people in need of care are less strongly pushed in caregiving role and they may escape the vicissitudes associated with caregiving. In our study we focused on two countries where coverage of long-term care services was traditionally extensive: Denmark and Sweden. However, cutbacks were implemented at the end of the 20th century in Sweden and more recently in Denmark.

We analyzed data from the Survey of Health, Ageing and Retirement in Europe collected between 2004 and 2015. Given that the coverage of long-term care services was more generous in Denmark and in Sweden for most of the period studied, we expected caregiving to be more detrimental for quality of life in the latter than in the former country. In line with these expectations, we noted a quality of life decline in Swedish, but not Danish, adult children when they became caregivers. Also as expected, the country difference in the detrimental effect of caregiving became smaller when further long-term care cutbacks took place in Denmark, but not in Sweden. These results strongly suggest that the extent to which providing informal care is harmful for quality of life depends on the way long-term care is organized in the country where the informal caregiver lives.

Guest blog post by Dr. Thijs van den Broek, Erasmus School of Health Policy & Management, Erasmus University Rotterdam, The Netherlands

Van den Broek, T. & Grundy, E. (2018). Does long-term care coverage shape the impact of informal care-giving on quality of life? A difference-in-difference approach. Ageing & Society.  https://doi.org/10.1017/S0144686X18001708

The research leading to these results has received funding from the European Research Council under the European Union’s Seventh Framework Programme (FP7/2007–2013)/ ERC grant agreement n° 324055.

 

Quality of life associated with handgrip strength and sarcopenia in Brazil

Geriatric syndromes, such as sarcopenia (the joint reduction of strength and muscle mass), although frequent in the population, can be prevented or delayed onset which can promote active and healthy aging. The study aims to verify the association between handgrip strength (HGS), sarcopenia, sarcopenic obesity and quality of life (QoL) in older adults from a major city of southern Brazil.

This study is part of a longitudinal, population-based and home-based epidemiological survey, EpiFloripa Aging, conducted with individuals aged 60 years or older from Florianópolis, Santa Catarina State, Brazil, in 2013/14. Multiple linear regression was performed to estimate the associations of handgrip strength (HGS – verified by mechanical dynamometer), sarcopenia (appendicular skeletal muscle mass by DXA /body weight <2 standard deviations below gender-specific means of young adults), sarcopenic obesity (obesity by percentage of body fat + sarcopenia), and the outcome of quality of life (CASP-16 Brazil), adjusted by age, family income, leisure and transportation physical activity, functional dependence, cognitive deficit and depressive symptoms.

Of the 1,197 of EpiFloripa follow-up, 604 older adults attended the laboratory, image and functional physical examination, and 584 underwent evaluation of body composition and HGS.  Considering the range of QoL score, from 0 to 48, the mean score was 38.2 (±7.2) and 39.3 (±6.5), respectively, for females and males.

Woman had a mean HGS of 17.9 kgf (±5.5), a prevalence of 6.6% (95%CI:3.9;10.8) of sarcopenia and 1.8% (95%CI: 0.9;3.3) of sarcopenic obesity. Among man HGS mean was 29.5 kgf (±8.5), 9.8% (95%CI:  5.6;16.6) presented sarcopenia and 14.2% (95%CI: 8.8;22.1) sarcopenic obesity.

Despite no statistical difference between the mean of QoL and the prevalence of sarcopenia or sarcopenic obesity, there was difference in the linear regression. In the adjusted analysis, at each increase of one kgf in HGS there was a 0.24 and 0.18 increase in the QoL score, for females and males, respectively. The sarcopenia was negatively associated with QoL, only in males, with a decrease of 3.06 points, but sarcopenic obesity wasn’t associated with QoL.

Considering the impact muscle and mass strength have on QoL, interventions that minimize the phenotypes related these conditions are fundamental. The adoption of exercises that improve the efficiency of muscular development and strength, as well as nutritional counseling, based on individual needs and socioeconomic level with a multi-professional team is emphasized. Since the HGS evaluation is a quick, simple, noninvasive and low-cost measure, it can be adopted by health professionals in the geriatric evaluation, and especially to become an important tool for monitoring and evaluate health groups results.

Guest blog by Larissa Pruner Marques – Researcher at EpiFloripa Aging Study, Department of Public Health, Federal University of Santa Catarina

Marques, L. P., Confortin, S. C., Ono, L. M., Barbosa, A. R., & d’Orsi, E. (2019). Quality of life associated with handgrip strength and sarcopenia: EpiFloripa Aging Study. Archives of gerontology and geriatrics81, 234- doi: 10.1016/j.archger.2018.12.015

The impact of access to prescription drugs on disability in eleven European countries

Clinical studies have shown that the use of certain drugs can reduce disability. Access to prescription drugs varies across countries. Figure 1 shows the number of new chemical entities (NCEs) that were launched in eleven European countries during the period 1982-2015. The average number of NCEs launched in the top 3 countries (709) was 42% higher than the number of NCEs launched in the bottom 3 countries (501).

Figure 1: Number of New Chemical Entities launched during 1982-2015, by country

Even when the total number of drugs launched in two countries is similar, the specific drugs that were launched, and the diseases those drugs are used to treat, may differ. As shown in Figure 2, at least two more drugs were launched in Italy than in Spain for four diseases, and at least two fewer drugs were launched in Italy for three other diseases. My study showed that the relative number of drugs launched for a disease in a country is higher when the relative prevalence of that disease is greater: “misery loves company.”

Figure 2: Difference between number of drugs launched during 1982-2015 for 7 diseases in Italy and Spain

As shown in Figure 3, relative disability from different diseases varies across countries: French people who had had chronic kidney disease and hip fractures were more likely to be severely limited than Germans, but French people who had had ulcers, breast cancer, and strokes were less likely to be severely limited than Germans.

Figure 3: Percent of people in France and Germany in 2015 with 5 medical conditions who were severely limited

In a recent paper, I tested the hypothesis that the larger the relative number of drugs for a disease that were launched during 1982-2015 in a country, the lower the relative disability in 2015 of patients with that disease in that country, controlling for the average level of disability in that country and from that disease, and the number of patients with the disease and their mean age. I analyzed several measures of disability for 31 diseases in eleven European countries using data from the Survey of Health, Ageing and Retirement in Europe (SHARE) and from other sources.

The estimates implied that drug launches during 1982-2015 reduced the probability of severe limitation in 2015 by 4.9 percentage points, from 21.8% to 16.9%; they reduced the probability of any limitation by 7.7 percentage points, from 61.1% to 53.4%; and they reduced the mean number of Activities of Daily Living limitations by about 29%. Drug launches also yielded a small increase in an index of quality of life and well-being.
I estimate that mean pharmaceutical expenditure on drugs launched after 1981 by people 45 and over in the eleven European countries was $611. Expenditure of $611 reduced the probability of being severely limited by 4.9 percentage points. If people would have been willing to pay at least $12,469 (= $611 / 4.9%) to avoid being severely limited, which is very likely, drugs launched during 1982-2015 would have been cost-effective, even if they did not provide any other benefits, e.g. increased longevity and reduced hospitalization. However previous research has demonstrated that new drug launches have also provided those benefits.

In general, the larger the number of drugs for a disease that were launched during 1982-2015 in a country, the lower the average disability in 2015 of patients with that disease in that country, controlling for the average level of disability in each country and from each disease, and the number of patients with the disease and their mean age.
The long-term reduction in disability attributable to increasing availability of prescription drugs may have been offset by adverse trends in behavioral risk factors, such as obesity. SHARE data indicate that the fraction of the population aged 50 and over that was obese (BMI > 30) increased from 17.1% in 2004 to 22.2% in 2015.

Previous research has demonstrated that new drug launches have reduced mortality: they have enabled people who would have died if the drugs had not been launched to remain alive. Presumably, those additional survivors were the most severely ill and disabled: biomedical innovation tends to offset natural selection. Therefore, the reduction in the average disability of living people due to new drug launches would probably have been even greater if the drugs had not reduced mortality.

Guest blog post by Prof. Frank R. Lichtenberg, PhD, Columbia University, National Bureau of Economic Research, and CESifo. First posted on the SHARE blog http://www.share-blog.eu/the-impact-of-access-to-prescription-drugs-on-disability-in-eleven-european-countries/

The article is based on:

Lichtenberg FR. (2019), The impact of access to prescription drugs on disability in eleven European countries, Disability and Health Journal, https://doi.org/10.1016/j.dhjo.2019.01.003.

Positive Psychology and Dementia: How the CASP-19 performed in a UK based study of older adults with dementia.

How people live well with a diagnosis of dementia is of increasing interest to clinicians and researchers and quality of life is now a widely accepted central outcome in psychosocial research. However, quality of life is one of the few positive concepts to be measured for this population and there is still an overriding focus on negative behavioural and psychological symptoms including depression and agitation. We believe that, whilst these measures have contributed to a wealth of understanding, a more balanced view of wellbeing is needed, where measures of the strengths or capabilities that people with dementia retain are routinely included in research.

During a PhD project from 2014 – 2017, we developed two such outcome measures: the Positive Psychology Outcome Measure (PPOM) that assessed hope and resilience and the Engagement and Independence in Dementia Questionnaire (EID-Q) that assessed levels of social engagement and subjective independence.

In addition to developing these measures, we elected to psychometrically assess the CASP-19 for older adults with dementia. This was based on its theoretical underpinning as a measure of the positive dimensions of ageing and its strong psychometric properties for older adults documented in a systematic review we performed previously.

From 2016 – 2017, we recruited 225 people with dementia (59 – 99 years old) across the UK and asked them to complete five outcome measures: the CASP-19, PPOM, EID-Q, Quality of Life in Alzheimer’s Disease (QoL-AD) and the Geriatric Depression Scale Short Form (GDS-15). We asked 48 people to complete the measures again, with a one-week period to assess whether the measures were stable over time.

Our analysis of the CASP-19 documented strong psychometric properties, with acceptable levels of internal consistency and no floor or ceiling effects apparent. We also documented that the CASP-19 showed good consistency over the test and retest period. Our results suggested that the CASP-19 has important implications for wellbeing for people with dementia as those scoring above 10 on the GDS-15, and therefore likely to be experiencing clinically relevant depressive symptomology, were more likely to score lower on the CASP-19 and vice versa. We also found strong positive correlations between the CASP-19, QoL-AD, PPOM and EID-Q, suggesting that these positive concepts are also related.

However, a factor analysis indicated that the 19-item CASP measure may not be the most appropriate for people with dementia. To establish which factor structure was superior, a series of confirmatory factor analyses (CFAs) were performed using structures evaluated in previous studies of the CASP-19. We concluded that a 12-item CASP, combing the control and autonomy subscale was the most robust model.

Our research suggests that the CASP-12 is a psychometrically sound measure of wellbeing for older adults with dementia and can be used in further research for this population. Further large-scale research conducted as part of the Promoting Independence in Dementia (PRIDE) programme will determine whether the CASP-12 can capture responsiveness to interventions; a key component of psychometric analysis.

Guest blog: Dr Charlotte R. Stoner, Research Department of Clinical, Educational and Health Psychology, University College London (UCL).

Stoner, C. R., Orrell, M. & Spector, A. (2018). The psychometric properties of the Control, Autonomy, Self-realisation and Pleasure Scale (CASP-19) for older adults with dementia. Aging & Mental Health, Jan12, 1-7.  https://www.tandfonline.com/doi/abs/10.1080/13607863.2018.1428940?journalCode=camh20

 

 

Boomerang children and parents’ quality of life in Europe

There have been many studies examining the effects of living with an adult child on parents’ physical and mental health. However, alternative pathways to intergenerational co-residence may have different or even opposite implications for parents’ well-being. In our study we used longitudinal data from four waves of the Survey of Health, Ageing and Retirement in Europe (2007-2015) to analyse whether returns to the parental home by adult children are associated with changes in parents’ quality of life.

Although other possible dependent variables, such as depressive symptoms, are available in SHARE, we chose to analyse parents’ Quality of Life (QoL) using the CASP-12 scale. Living under the same roof after a period of independence may lead to a new family equilibrium where both parents and adult children negotiate their spaces and activities harmoniously. However, returns by adult children to the parental home may in other cases challenge valued autonomy or disrupt a life stage in which parents enjoy hobbies and daily activities without the responsibility for children. The CASP scale which includes the four dimensions of Control, Autonomy, Self-Realization and Pleasure fits our research purpose particularly well.

The analysis was performed on parents aged 50-75 in order to reduce the chance that home returning was due to parents’ healthcare needs. Intergenerational co-residence of frail elderly parents and caregiving children may have different implications for parents’ QoL. In our analytical sample, only two per cent of parents had a child moving back home, indicating that returning to the parental home is a quite rare phenomenon in Europe.

Results from fixed effects regression models show that parents’ QoL decreased when a child returned to the parental home, and this effect was mainly driven by children who moved back to an empty nest. This provides evidence that parents enjoy their independence and daily activities when their children leave the home, and returns to an empty nest may disrupt this life course stage.

We analysed whether parent’s QoL decreased more when the returning child was unemployed or divorced as it might be that the reason for returning home, rather than the move per se, was related to a decline in parents’ QoL. Although children’s job loss was negatively associated with parents’ QoL, there were no associations between changes in parental quality of life and the returning child’s characteristics.

A further research question addressed in this study is related to the varying effects that returns to the parental home may have across different European societies. The findings show that returns home by adult children were associated with a decline in parent’s QoL in Nordic countries where autonomy and family independence have a greater value. In sum, our results suggest that home returning has a negative effect on parents’ QoL in a grouping of Nordic countries and when no other children lived in the family nest.

Guest blog post by Dr Marco Tosi, ALPHA Research Unit, Department of Social Policy, London School of Economics

Tosi, M., & Grundy, E. (2018). Returns home by children and changes in parents’ well-being in Europe. Social Science & Medicine.

Paper: https://www.sciencedirect.com/science/article/pii/S0277953618300169.

The research leading to these results has received funding from the European Research Council under the European Union’s Seventh Framework Programme (FP7/2007–2013)/ ERC grant agreement n° 324055.

Why people work after State Pension Age and does this affects their quality of life? Evidence from ELSA.

The age at which workers retire is increasing, largely due to policy changes designed to extend working lives, including raising the state pension age (SPA). However, this trend toward working longer is relatively new and, so far, little is known about why some people work beyond SPA and whether, and to what extent, this affects their well-being.

Continued work after SPA might provide workers with an opportunity to engage in physical, cognitive, and social activities leading to higher quality of life (QoL). However, a reverse effect is also possible if those extending their working lives do so because they feel that they ‘have to’ (for instance, out of financial necessity).

In a recent publication (Di Gessa et al., 2017), we used data from the English Longitudinal Study of Ageing (ELSA) to better understand why older people are in paid work beyond SPA, and whether these reasons are associated –both cross-sectionally and over time –with QoL measured using the CASP-19 scale.

In our analyses, we selected ELSA respondents who had reached the current SPA (65 for men, and 60 for women in 2008/09). In particular, we considered men aged 65-74 and women aged 60-69 who were interviewed in 2008/09 and in 2014/15. We excluded older respondents as few men and women work beyond 74 and 69, respectively.

Who works beyond SPA and why?

About one respondent in five reported working beyond SPA. This is comparable to data from the Labour Force Survey which shows that 23% of women aged 60-69 and 16% of men aged 65-74 were in paid employment in the UK in 2009.

Of those working beyond SPA, about two thirds reported that they were in paid work ‘voluntarily’, i.e. because they ‘enjoy working’ or to ‘keep active and fit’; the other third, however, reported financial issues as their main reason to work (i.e. because they ‘could not afford to retire earlier’ or wanted to ‘improve their pension/financial position’).

Table 1 shows CASP-19 scores by employment status. Respondents working voluntarily reported the highest QoL (CASP-19= 45.4) whereas the lowest QoL was reported by those who retired involuntarily (CASP-19=38.9). To give an idea of the effect sizes, a similar difference of about 7 CASP-19 points was found between respondents who reported no longstanding illness and those with a limiting longstanding illness. As expected, respondents with more advantageous socio-economic characteristics and better health reported higher baseline CASP-19 scores.

 

Table 1. Baseline unadjusted CASP-19 score by employment status, ELSA 2008/09

  % in sample Mean CASP-19 score
Retired at SPA 27.8 41.9 (0.31)
Voluntarily retired 27.7 44.4 (0.26)
Involuntarily retired 24.6 38.9 (0.36)
In paid work, financial necessity 6.8 41.0 (0.65)
In paid work, voluntarily 13.1 45.4 (0.36)

 

The results of a series of linear regression models show that, even once we take into account the socio-economic and health characteristics of the respondents, the reasons for being in paid work were significantly associated with CASP-19 scores. Those in paid work beyond SPA out of financial necessity were significantly associated with worse QoL (β=-1.21) compared to those who had retired at the expected/usual age. On the other hand, respondents who voluntary extended their working lives reported significantly better QoL (β=1.62). Among retirees, those who reported voluntary retirement were significantly more likely to report higher QoL (β=1.12).

When we focus on changes over time, only respondents who stopped working between waves but who had previously worked beyond SPA voluntarily reported improvements in CASP-19 scores (β=0.97), although this was only marginally significant (p<0.10). In contrast, involuntary retirement six years earlier had an enduring negative effect on QoL (β=-1.59).

In sum, our results suggest those working beyond SPA for positive reasons (about two thirds of workers) report the highest levels of QoL, and also experience marginal improvements in QoL when they eventually leave the labour market. This is most likely because they have control over both the initial decision and the following transition. In contrast, those working beyond SPA out of financial necessity (one third of workers) report a CASP-19 score of about 4 points lower at baseline, and this level is unlikely to rebound upon eventual retirement. In light of the association between QoL and adverse health outcomes, including mortality, this is particularly worrisome.

Understanding why people continue working past SPA, and its implications for health and well-being across social groups is important given the potential for some social groups to be disproportionately disadvantaged by longer working lives. While initiatives aimed at helping workers maintain control over the decision to extend their employment are worthwhile, policy makers must also consider mechanisms to support individuals across the life course to ensure a minimum financial well-being in later life in order to mitigate the negative implications for QoL of having to work longer.

Guest blog post by Dr Giorgio Di Gessa, LSE Fellow in Population Health/Global Ageing, Department of Social Policy, LSE

Reference

Di Gessa, G; Corna, L.; Price, D; and Glaser K (2017). The decision to work after State Pension Age and how it affects Quality of Life: Evidence from a 6-year English panel study. Age and Ageing DOI: 10.1093/ageing/afx181

Quality of life amongst older people in Colombia

The aim of the study was to evaluate the Quality of Life and its relationship with salutogenic and pathogenic variables in 150 Colombian elderly people over 60 years old (x̄ = 72.4, SD = 7.33), 68 of them were men (45.3%) and 82 women (54.7%). To measure quality of life (QoL) we used the CASP-19 scale. We were also interested to look at resilience, and anxiety and depression as potential factors that might be associated with QoL.

Contrasting results between older Colombians study (CEP) and the English Longitudinal Study of Ageing (ELSA), whose sample was larger than 6000 people over 60 years (x̄ = 7.61), there were some differences in quality of life (QoL) (see table 1). The Control dimension had a slightly higher average score in the CEP (x̄ = 7.87) than in ELSA. This suggests that older Colombians feel that they are able to actively participate with their environment. The Autonomy dimension had average scores lower in the CEP (x̄ = 8.96) than in ELSA (x̄ = 9.74). This suggests that older Colombians face a lot of external interference when trying to do the things that they want to do. The Pleasure dimension were higher on average in the CEP (x̄ = 10.04) than in ELSA (x̄ = 7.61), indicating that older people in Colombia are generally happy and feel that they can make a commitment to themselves and their life. The Self-realization scores were lower on average in the CEP (x̄ = 13.09) than those in ELSA (x̄ = 13.17). This suggests that older people in Colombia might face some obstacles to fulfilling their goals and potential. Finally, the scores for the overall CASP-19 scale were on average scores slightly lower in the CEP (x̄ = 39.96) than in ELSA (x̄ = 40.96). However, these are still high average scores indicating that older Colombians enjoy a good quality of life in general and that they are conscious of the positive aspects of life.

Table 1. Descriptive statistics of the variables Quality of Life, resilience, anxiety, depression

S.D Minimum Maximum
CASP-19: Quality of Life
-Control 7.87 2.93 0 12
-Autonomy 8.96 2.74 0 15
-Pleasure 10.04 2.36 0 12
– Self-realization 13.09 3.63 0 18
– Total scale CASP-19 39.96 9.06 0 55
CLHLS: Resilience 19.1 4.28 0 25
PHQ-4: Anxiety 1.13 1.29 0 6
PHQ-4: Depression 1.09 1.28 0 6

Nonetheless we also found some negative relationships between certain dimensions of QoL and other variables in the study. Control was negatively associated with anxiety (rho = -0.32: p <0.01) and depression (rho = -0,32: p <, 01). Self-realization was also negatively associated with depression (rho = -0,35: p <, 01). This indicates that depression could be a major factor that reduces QoL in later life in Colombia. As such steps should be taken to combat anxiety and depression amongst older Colombians. Conversely, we found positive relationships between resilience and Control (rho = 0.60: p <0.01), Autonomy (rho = 0.39: p <0, 01), Self-realization (rho = 0.58: p <0.01) and overall CASP-19 scale (rho = 0.70: p <0.01).

The results of this study partially confirm what was found in the research done in England, whose objective was to investigate whether the social context and socioeconomic circumstances, impacted on QoL in later life. The fact, that in this study a large part of the sample were women (54.7%) with an average age of 72 years, of marital status married (48%) that lived with relatives (78.7%), registered in Colombian´s health system (100%), belonging to middle-low strata of the called Colombian Andean culture, at an period where culturally a high matriarchal status is given within family networks, where broad social support is given and received throughout their lives, makes us think that these factors contributed in a significant way to the good results in quality of life found in this study.

Reference: Vinaccia, S., Riveros., García, L., Quiceno, J.M., Martínez, O.V., Martínez, M., y Reyes, K. (2018) Variables sociodemográficas y de salud asociadas a la calidad de vida en adultos mayores Colombianos. Psicología y Salud, 28(1), 73-83

Guest blogger: Stefano Vinaccia Alpi, SANITAS University Foundation, Bogotá