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Aging & Mental Health Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/camh20
Association of quality of life with laboratory measurements and lifestyle factors in community dwelling older people in Taiwan abc
Tai-Yin Wu jk
ab
de
fghi
, Wei-Chu Chie , Jen-Pei Liu , Chen-Kun Liaw
, Gopalakrishnan
kl
Netuveli & David Blane a
Institute of Epidemiology and Preventive Medicine, National Taiwan University, Taipei, Taiwan b
Department of Public Health, College of Public Health, National Taiwan University, Taipei, Taiwan c
Department of Family Medicine, Renai Branch, Taipei City Hospital, Taipei, Taiwan
d
Click for updates
Division of Biometrics, Department of Agronomy and Institute of Epidemiology, National Taiwan University, Taipei, Taiwan e
Division of Biometrics and Bioinformatics, Institute of Population Health Sciences, National Health Research Institutes, Zhunan, Taiwan f
Department of Orthopedics, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
g
School of Medicine, National Taiwan University, Taipei, Taiwan
h
School of Medicine, Fu-Jen Catholic University, New Taipei City, Taiwan
i
Department of Healthcare Information and Management, Ming Chuan University, Taoyuan County, Taiwan j
Institute of Health and Human Development, Stratford Campus, University of East London, London, United Kingdom k
International Centre for Life Course Studies in Society and Health, University College London, London, United Kingdom l
Department of Epidemiology and Public Health, University College London, London, United Kingdom Published online: 30 Sep 2014.
To cite this article: Tai-Yin Wu, Wei-Chu Chie, Jen-Pei Liu, Chen-Kun Liaw, Gopalakrishnan Netuveli & David Blane (2015) Association of quality of life with laboratory measurements and lifestyle factors in community dwelling older people in Taiwan, Aging & Mental Health, 19:6, 548-559, DOI: 10.1080/13607863.2014.962000 To link to this article: http://dx.doi.org/10.1080/13607863.2014.962000
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any
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Aging & Mental Health, 2015 Vol. 19, No. 6, 548 559, http://dx.doi.org/10.1080/13607863.2014.962000
Association of quality of life with laboratory measurements and lifestyle factors in community dwelling older people in Taiwan Tai-Yin Wua,b,c, Wei-Chu Chiea,b*, Jen-Pei Liud,e, Chen-Kun Liawf,g,h,i, Gopalakrishnan Netuvelij,k and David Blanek,l
Downloaded by [New York University] at 12:46 25 May 2015
a Institute of Epidemiology and Preventive Medicine, National Taiwan University, Taipei, Taiwan; bDepartment of Public Health, College of Public Health, National Taiwan University, Taipei, Taiwan; cDepartment of Family Medicine, Renai Branch, Taipei City Hospital, Taipei, Taiwan; dDivision of Biometrics, Department of Agronomy and Institute of Epidemiology, National Taiwan University, Taipei, Taiwan; eDivision of Biometrics and Bioinformatics, Institute of Population Health Sciences, National Health Research Institutes, Zhunan, Taiwan; fDepartment of Orthopedics, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan; gSchool of Medicine, National Taiwan University, Taipei, Taiwan; hSchool of Medicine, Fu-Jen Catholic University, New Taipei City, Taiwan; iDepartment of Healthcare Information and Management, Ming Chuan University, Taoyuan County, Taiwan; jInstitute of Health and Human Development, Stratford Campus, University of East London, London, United Kingdom; kInternational Centre for Life Course Studies in Society and Health, University College London, London, United Kingdom; lDepartment of Epidemiology and Public Health, University College London, London, United Kingdom
(Received 20 March 2014; accepted 2 September 2014) Objectives: Little is known about the influence of routine laboratory measurements and lifestyle factors on generic quality of life (QOL) at older ages. We aimed to study the relationship between generic QOL and laboratory measurements and lifestyle factors in community dwelling older Chinese people. Methods: We conducted a cross-sectional analysis. Six hundred and ninety nine elders were randomly selected from the examinees of the annual health examination in Taipei City, Taiwan. Blood, urine and stool of the participants were examined and lifestyle data were collected. Participants completed the CASP-19 (control, autonomy, self-realization, pleasure) questionnaire, a 19-item QOL scale. The relationship between QOL and laboratory results and lifestyle factors was explored, using multiple linear regression and profile analysis. Results: The mean age of the participants was 75.5 years (SD D 6.5), and 49.5% were female. Male gender standardized b coefficients (b D 0.122) and exercise habit (b D 0.170) were associated with a better QOL, whereas advanced age (b D ¡0.242), blurred vision (b D ¡0.143), depression (b D ¡0.125), central obesity (b D ¡0.093), anemia (b D ¡0.095), rheumatoid arthritis (b D ¡0.073), Parkinsonism (b D ¡0.079), malignancy (b D ¡0.086) and motorcycle riding (b D ¡0.086) were associated with a lower QOL. Profile analysis revealed that young old males, social drinkers, regular exercisers and car drivers had the best QOL (all p < 0.001). Conclusion: Of the many laboratory measurements, only anemia was associated with the lower QOL. By contrast, several lifestyle factors, such as social drinking, exercise habit and car driving, were associated with better QOL, whereas abdominal obesity and motorcycle riding were associated with lower QOL. Keywords: quality of life; old age; lifestyle factors; clinical status
Introduction Traditionally, aging is perceived to decrease quality of life (QOL) (Williams, 1977). The emergence of a Third Age (the years from retirement to physical dependency) demands further investigation into other predictors of QOL (Netuveli, Wiggins, Hildon, Montgomery, & Blane, 2006). The population in Taiwan is 23 million. Older people constituted 10.2% of the total population in the year 2010. In the capital Taipei City, particularly, the rate was 12.7% (Ministry of Interior, 2014, August 6). One-fourth (27.5%) of the older people live in the urban areas. Nationwide, one-fourth (27.2%) reported that they were in poor health, the majority (75.9%) had certain chronic condition, but 78.0% was satisfied about their current life. Half (55.0%) participated regularly in some form of social activity, mainly health preservation or recreational social groups and religious activities. The ideal living mode for most Taiwanese older people was living with their children (68.5%), and 67.7% of them actually lived so. The *Corresponding author. Email: [email protected] Ó 2014 Taylor & Francis
main financial source for most of the older people came from their children. In the Taiwanese culture, being able to eat the desired food as well as having a good reputation from other people is a great well-being (Yao, 2002). Owing to the tropical climate and the small and winding lanes in the urban areas, motorcycle is an important local transportation. There are 15 million motorcycles in Taiwan (Ministry of Transportation and Communications, 2014). However, the motorcycle-related traffic accident rates are also high. There is a literature which documents that a person’s health is associated with the health-related QOL (HRQOL). Physical health can be quantified using laboratory investigations and is related to lifestyle factors. They are different facets of physical health. How these health indicators including laboratory measurements, chronic conditions and personal lifestyle effect on QOL in older people in Taiwan is an issue of concern.
Downloaded by [New York University] at 12:46 25 May 2015
Aging & Mental Health Among the common laboratory measurements, chronic anemia is associated with constitutional symptoms and impacts negatively on QOL (Lash & Coyer, 2008). In patients with immune thrombocytopenia, HRQOL is reduced (Kuter et al., 2012). Minimal literature explored the relationship between leukocyte counts and QOL. A common cause of elevated liver function is viral hepatitis. Treatment of viral hepatitis has a positive effect on HRQOL (Cordoba et al., 2003). Even moderately decreased renal function is associated with a decreased HRQOL (Chin et al., 2008). Proteinuria as an early sign of renal impairment has a profound effect on HRQOL (Kelley, Aricak, Light, & Agarwal, 2007). Good HRQOL is related to good blood sugar control (Navicharern, 2012). Low-cholesterol level in midlife predicts better HRQOL in old age (Hyttinen et al., 2011). Both hyperthyroidism and hypothyroidism exert systemic effects. Ablative surgery for symptomatic hyperthyroidism improves HRQOL (Adler, Sippel, Schaefer, & Chen, 2008), and hypothyroidism under treatment is associated with poor HRQOL (Vigario et al., 2013). Vitamin D deficiency has a wide array of biological influences and is independently associated with lower HRQOL (Ulitsky et al., 2011). Osteoporosis can be largely symptomless. However, HRQOL is impaired in patients with reduced bone mineral density (Romagnoli et al., 2004). There is evidence that disabling health conditions, such as poor vision (Eichenbaum, 2012), rheumatoid conditions or joint disease (Shin, 2012), have an impact on HRQOL. Several studies also linked health behaviors with QOL. Blane et al. reported that obesity was inversely associated with QOL (Blane, Netuveli, & Montgomery, 2008). Martin et al. proposed that exercise-induced HRQOL improvements were dose dependent (Martin, Church, Thompson, Earnest, & Blair, 2009). Lang et al. proposed that smoking was associated with poorer overall QOL (Lang, Gardener, Huppert, & Melzer, 2007). Strandberg et al. observed that the highest alcohol consumption was associated with worse QOL, and moderate alcohol consumption offered no special benefits compared with abstinence (Strandberg, Strandberg, Salomaa, Pitkala, & Miettinen, 2004). Plaisted et al. suggested that the combined fruits and vegetables diet improved HRQOL (Plaisted, Lin, Ard, McClure, & Svetkey, 1999). However, the relationship between QOL and car driving, motorcycle riding, betel but chewing, teeth brushing, and milk consumption remains unknown. In general, most existent literature evaluated the association between health status and HRQOL rather than generic and age-specific QOL. However, QOL is different from HRQOL. HRQOL mainly equates to impairment and disability and is just one of the contributors to generic QOL (Doward & McKenna, 2004). By contrast, life derives its quality from the ability of people to satisfy certain human needs. QOL is good when most needs are fulfilled and is a reflection of the way in which the older people perceive and react to their health status and to other non-medical aspects of their lives (Doward & McKenna, 2004). QOL goes beyond the impairment disability handicap continuum assessed by the HRQOL measurements (Tennant & McKenna, 1995).
549
The value of assessing QOL in addition to HRQOL should never be overlooked (Bradley, 2001). To obtain a complete picture of the impact of clinical conditions, it is essential to measure generic QOL (Doward & McKenna, 2004). Focusing on HRQOL alone might be insufficient. The relationship between the physiological laboratory measurements and generic QOL is little documented. This is the first extensive study of the relationship between routine laboratory tests, lifestyle and generic QOL. We aimed to analyze the relationship between various clinical conditions and lifestyle factors and generic QOL in old age, using the CASP-19 (control, autonomy, self-realization, pleasure) questionnaire. Our theoretical frame is that through the impact on overall bio psycho socio cultural functioning, the poor laboratory test results would be inversely while healthy lifestyles are positively associated with QOL in old age, as shown in Figure 1. Methods We conducted a hospital-based, cross-sectional study in the year 2010. Each year, the Taipei City Government provides a free health examination to all the residents aged over 65 and to native Taiwanese over 55 years. Our population of interest was community dwelling senior citizens in the Taipei City, Taiwan. Eligible candidates were health examinees from a city hospital. Exclusion criteria included inability to provide reliable data, cognitive impairment and difficulty communicating face to face. This city hospital is where the first author and the only research assistant work and is located in one of the wealthiest living areas of the capital. We wish we could enroll more hospitals. However, since this was a smallscale study with limited funding and scarce human resource at the beginning, we were not able to do so. A total of 3680 health examinees were identified. Onefifth of those examinees were randomly selected for questionnaire interview by drawing lots. The interview took place in the same morning right after the health exam. Refusal rate of the older people we approached was roughly 30% 40%. Informed consents were obtained from those who agreed to participate. The study was approved by the Institutional Review Board of the Taipei City Hospital [TCHIRB-990204]. We chose our parameters based on the health examination and questionnaire items, which consisted of collection of general demographic and lifestyle data, physical examination and blood, urine and stool tests. Self-reported lifestyle factors included tobacco smoking, alcohol consumption, betel nut chewing, teeth brushing, milk consumption, intake of fruits and vegetables, regular exercise and motorcycle riding or car driving. Alcohol consumption was classified as no drinking, social drinking or habitual drinking. Exercise habit was classified as no exercise, occasional exercise or regular exercise three to five times weekly. Body stature measurements were based on the national guidelines. The body mass index (BMI, kg/m2) cut-off values for underweight, normo-weight, overweight, mild obesity and moderate to severe obesity were 18.5, 24, 27 and 30, respectively. Central obesity was
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550
T.-Y. Wu et al.
Figure 1. Theoretical framework of this study.
defined as abdominal girth 80 cm and 90 cm in females and males, respectively. Blood tests included complete blood count and biochemistry profile (blood sugar, liver function, kidney function, lipid profile). Certain enrollees were further tested for serum vitamin D (25-hydroxyvitamin D), lowdensity lipoprotein, thyroid stimulating hormone, a fetoprotein, prostate specific antigen levels and bone mineral density. Samples were analyzed in the core laboratories of the Taipei City Hospital. The bone mineral density was measured by dual energy X-ray absorptiometry (Hologic Explorer QDR, USA). Osteoporosis was defined as T score ¡2.5. An interviewer-administered questionnaire assessed longstanding illnesses and generic QOL, using the CASP19 scale. CASP-19 is a 19-item Likert-scaled index of generic QOL at older ages, which intended to be independent of its main predictors such as health (Netuveli et al., 2006). CASP-19 accesses the domains ‘control (C)’, ‘autonomy (A)’, ‘self-realization (S)’ and ‘pleasure (P)’ (Blane et al., 2008). Control is the ability to actively intervene in one’s environment. Autonomy is freedom from interference from the others. Pleasure and self-realization are the active and reflexive processes of being human (Hyde, Wiggins, Higgs, & Blane, 2003). Higher scores corresponded to a better QOL. CASP-19 has been used in many major international studies. CASP-19 Chinese Taiwan version is a validated standard instrument (Wu et al., 2013). The five-factor model of CASP-19 we proposed has varied items in each domain (2, 2, 5, 6 and 4 items for control, autonomy, self-realization, pleasure and participation, respectively), which makes comparison between domain scores difficult. Also to facilitate international
comparison, we choose to use the original four-factor model in this study. Chronic condition assessment was based on history of 28 common diseases. Polypharmacy was defined as concomitant use of more than four drugs. Self-reported loss of body height was defined as a greater than 3 cm decrease in stature after the age of 40. All analyses were performed using SPSS 14.0 Chinese version (SPSS Inc., Chicago, IBM Company, USA). We dichotomized participants into subgroups according to their laboratory test results (normal vs. above or below reference range, with values provided by the laboratory). This dichotomization based on clinical significance is a common daily practice. Missing data were typically 1 PPD Current drinking No Social Habitual Current betel nut chewing No Yes
N
%
25 344 206 82 25
3.7 50.4 30.2 12.0 3.7
417 266
61.1 38.9
627 28 21 7
91.8 4.1 3.1 1.0
509 156 18
74.5 22.8 2.6
677 6
99.1 0.9
Lifestyle factors Teeth brushing No Once a day Twice a day three times a day Fruits and vegetables everydaya No Yes Milk everyday No Yes Exercise habit No Occasional Regular Driving or riding None Car driving Motorcycle riding
N
%
7 53 382 241
1.0 7.8 55.9 35.3
160 523
23.4 76.6
291 392
42.6 57.4
40 209 434
5.9 30.6 63.5
575 77 31
84.2 11.3 4.5
a
Taking two portions of fruits and three portions of vegetables every day.
driving habits. There were significant differences in QOL among participants as grouped by their age and gender, drinking habit, exercise habit, and riding/driving habit (all p < 0.001). The younger male group had the highest CASP-19 scores as compared to their older or female counterparts. Social drinkers, those who exercised regularly and drivers had the best QOL. The control and the pleasure were the domains with the lowest and highest summated scores (8.4 and 11.8, respectively; p < 0.001). Post hoc analysis revealed that the differences in QOL domain scores existed between younger male group and the rest, older and younger females, social drinkers and
Figure 2. Distribution of CASP-19 total score of the participants.
non-drinkers, non-exercisers and the rest, and drivers and the rest.
Discussion We observed that the advanced age, female gender, blurred vision, certain chronic conditions (depression, rheumatoid arthritis, Parkinson’s disease, and malignancy), anemia, central obesity and motorcycle riding were associated with a lower generic QOL, whereas social drinking, regular exercise and car driving were associated with a higher generic QOL in old age. The total score of the CASP scale differed significantly among subgroups of participants in terms of age and gender. Tsai et al. reported that in Taiwan, the rural elderly women had the poorest HRQOL (Tsai, Chi, Lee, & Chou, 2004). Our findings that men in early old age had the best QOL is consistent with this observation. In the traditional Chinese culture, women’s social position was lower than men’s. This may be the reason for our findings. Steptoe et al. have suggested that positive psychological well-being has biological correlates that may be health protective (Steptoe, Demakakos, de Oliveira, & Wardle, 2012). To our surprise, all laboratory measurements were not associated with generic QOL, except for anemia. By contrast, certain self-reported longstanding illnesses had negative impacts on QOL. As functional limitation is the key dimension of health in its relationship with QOL (Gunaydin, Karatepe, Kaya, & Ulutas, 2011), it is the impact of disease on social functioning that influences QOL rather than the laboratory results by themselves. Poor objective measurements may not equate to poor QOL.
Aging & Mental Health
553
Table 3. Laboratory test results of the participants and the CASP-19 total score (n D 699). Presenta
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Characteristics Blood tests Anemia (hemoglobin 42 U/L) Renal insufficiency (BUN 24 mg/dL or Cr 1.3 mg/dL) Preprandial hyperglycemia (>100 mg/dL) Hypercholesterolemia (>200 mg/dL) Hypertriglyceridemia (150 mg/dL) High LDL (>130 mg/dL) (n D 214) Hyperthyroidism (5 m units/mL) (n D 251) Elevated AFP (10 mg/L) (n D 251) Elevated PSA (5 ng/mL) (males only) (n D 218) Vitamin D deficiency (
Aging & Mental Health Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/camh20
Association of quality of life with laboratory measurements and lifestyle factors in community dwelling older people in Taiwan abc
Tai-Yin Wu jk
ab
de
fghi
, Wei-Chu Chie , Jen-Pei Liu , Chen-Kun Liaw
, Gopalakrishnan
kl
Netuveli & David Blane a
Institute of Epidemiology and Preventive Medicine, National Taiwan University, Taipei, Taiwan b
Department of Public Health, College of Public Health, National Taiwan University, Taipei, Taiwan c
Department of Family Medicine, Renai Branch, Taipei City Hospital, Taipei, Taiwan
d
Click for updates
Division of Biometrics, Department of Agronomy and Institute of Epidemiology, National Taiwan University, Taipei, Taiwan e
Division of Biometrics and Bioinformatics, Institute of Population Health Sciences, National Health Research Institutes, Zhunan, Taiwan f
Department of Orthopedics, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
g
School of Medicine, National Taiwan University, Taipei, Taiwan
h
School of Medicine, Fu-Jen Catholic University, New Taipei City, Taiwan
i
Department of Healthcare Information and Management, Ming Chuan University, Taoyuan County, Taiwan j
Institute of Health and Human Development, Stratford Campus, University of East London, London, United Kingdom k
International Centre for Life Course Studies in Society and Health, University College London, London, United Kingdom l
Department of Epidemiology and Public Health, University College London, London, United Kingdom Published online: 30 Sep 2014.
To cite this article: Tai-Yin Wu, Wei-Chu Chie, Jen-Pei Liu, Chen-Kun Liaw, Gopalakrishnan Netuveli & David Blane (2015) Association of quality of life with laboratory measurements and lifestyle factors in community dwelling older people in Taiwan, Aging & Mental Health, 19:6, 548-559, DOI: 10.1080/13607863.2014.962000 To link to this article: http://dx.doi.org/10.1080/13607863.2014.962000
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any
Downloaded by [New York University] at 12:46 25 May 2015
form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
Aging & Mental Health, 2015 Vol. 19, No. 6, 548 559, http://dx.doi.org/10.1080/13607863.2014.962000
Association of quality of life with laboratory measurements and lifestyle factors in community dwelling older people in Taiwan Tai-Yin Wua,b,c, Wei-Chu Chiea,b*, Jen-Pei Liud,e, Chen-Kun Liawf,g,h,i, Gopalakrishnan Netuvelij,k and David Blanek,l
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a Institute of Epidemiology and Preventive Medicine, National Taiwan University, Taipei, Taiwan; bDepartment of Public Health, College of Public Health, National Taiwan University, Taipei, Taiwan; cDepartment of Family Medicine, Renai Branch, Taipei City Hospital, Taipei, Taiwan; dDivision of Biometrics, Department of Agronomy and Institute of Epidemiology, National Taiwan University, Taipei, Taiwan; eDivision of Biometrics and Bioinformatics, Institute of Population Health Sciences, National Health Research Institutes, Zhunan, Taiwan; fDepartment of Orthopedics, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan; gSchool of Medicine, National Taiwan University, Taipei, Taiwan; hSchool of Medicine, Fu-Jen Catholic University, New Taipei City, Taiwan; iDepartment of Healthcare Information and Management, Ming Chuan University, Taoyuan County, Taiwan; jInstitute of Health and Human Development, Stratford Campus, University of East London, London, United Kingdom; kInternational Centre for Life Course Studies in Society and Health, University College London, London, United Kingdom; lDepartment of Epidemiology and Public Health, University College London, London, United Kingdom
(Received 20 March 2014; accepted 2 September 2014) Objectives: Little is known about the influence of routine laboratory measurements and lifestyle factors on generic quality of life (QOL) at older ages. We aimed to study the relationship between generic QOL and laboratory measurements and lifestyle factors in community dwelling older Chinese people. Methods: We conducted a cross-sectional analysis. Six hundred and ninety nine elders were randomly selected from the examinees of the annual health examination in Taipei City, Taiwan. Blood, urine and stool of the participants were examined and lifestyle data were collected. Participants completed the CASP-19 (control, autonomy, self-realization, pleasure) questionnaire, a 19-item QOL scale. The relationship between QOL and laboratory results and lifestyle factors was explored, using multiple linear regression and profile analysis. Results: The mean age of the participants was 75.5 years (SD D 6.5), and 49.5% were female. Male gender standardized b coefficients (b D 0.122) and exercise habit (b D 0.170) were associated with a better QOL, whereas advanced age (b D ¡0.242), blurred vision (b D ¡0.143), depression (b D ¡0.125), central obesity (b D ¡0.093), anemia (b D ¡0.095), rheumatoid arthritis (b D ¡0.073), Parkinsonism (b D ¡0.079), malignancy (b D ¡0.086) and motorcycle riding (b D ¡0.086) were associated with a lower QOL. Profile analysis revealed that young old males, social drinkers, regular exercisers and car drivers had the best QOL (all p < 0.001). Conclusion: Of the many laboratory measurements, only anemia was associated with the lower QOL. By contrast, several lifestyle factors, such as social drinking, exercise habit and car driving, were associated with better QOL, whereas abdominal obesity and motorcycle riding were associated with lower QOL. Keywords: quality of life; old age; lifestyle factors; clinical status
Introduction Traditionally, aging is perceived to decrease quality of life (QOL) (Williams, 1977). The emergence of a Third Age (the years from retirement to physical dependency) demands further investigation into other predictors of QOL (Netuveli, Wiggins, Hildon, Montgomery, & Blane, 2006). The population in Taiwan is 23 million. Older people constituted 10.2% of the total population in the year 2010. In the capital Taipei City, particularly, the rate was 12.7% (Ministry of Interior, 2014, August 6). One-fourth (27.5%) of the older people live in the urban areas. Nationwide, one-fourth (27.2%) reported that they were in poor health, the majority (75.9%) had certain chronic condition, but 78.0% was satisfied about their current life. Half (55.0%) participated regularly in some form of social activity, mainly health preservation or recreational social groups and religious activities. The ideal living mode for most Taiwanese older people was living with their children (68.5%), and 67.7% of them actually lived so. The *Corresponding author. Email: [email protected] Ó 2014 Taylor & Francis
main financial source for most of the older people came from their children. In the Taiwanese culture, being able to eat the desired food as well as having a good reputation from other people is a great well-being (Yao, 2002). Owing to the tropical climate and the small and winding lanes in the urban areas, motorcycle is an important local transportation. There are 15 million motorcycles in Taiwan (Ministry of Transportation and Communications, 2014). However, the motorcycle-related traffic accident rates are also high. There is a literature which documents that a person’s health is associated with the health-related QOL (HRQOL). Physical health can be quantified using laboratory investigations and is related to lifestyle factors. They are different facets of physical health. How these health indicators including laboratory measurements, chronic conditions and personal lifestyle effect on QOL in older people in Taiwan is an issue of concern.
Downloaded by [New York University] at 12:46 25 May 2015
Aging & Mental Health Among the common laboratory measurements, chronic anemia is associated with constitutional symptoms and impacts negatively on QOL (Lash & Coyer, 2008). In patients with immune thrombocytopenia, HRQOL is reduced (Kuter et al., 2012). Minimal literature explored the relationship between leukocyte counts and QOL. A common cause of elevated liver function is viral hepatitis. Treatment of viral hepatitis has a positive effect on HRQOL (Cordoba et al., 2003). Even moderately decreased renal function is associated with a decreased HRQOL (Chin et al., 2008). Proteinuria as an early sign of renal impairment has a profound effect on HRQOL (Kelley, Aricak, Light, & Agarwal, 2007). Good HRQOL is related to good blood sugar control (Navicharern, 2012). Low-cholesterol level in midlife predicts better HRQOL in old age (Hyttinen et al., 2011). Both hyperthyroidism and hypothyroidism exert systemic effects. Ablative surgery for symptomatic hyperthyroidism improves HRQOL (Adler, Sippel, Schaefer, & Chen, 2008), and hypothyroidism under treatment is associated with poor HRQOL (Vigario et al., 2013). Vitamin D deficiency has a wide array of biological influences and is independently associated with lower HRQOL (Ulitsky et al., 2011). Osteoporosis can be largely symptomless. However, HRQOL is impaired in patients with reduced bone mineral density (Romagnoli et al., 2004). There is evidence that disabling health conditions, such as poor vision (Eichenbaum, 2012), rheumatoid conditions or joint disease (Shin, 2012), have an impact on HRQOL. Several studies also linked health behaviors with QOL. Blane et al. reported that obesity was inversely associated with QOL (Blane, Netuveli, & Montgomery, 2008). Martin et al. proposed that exercise-induced HRQOL improvements were dose dependent (Martin, Church, Thompson, Earnest, & Blair, 2009). Lang et al. proposed that smoking was associated with poorer overall QOL (Lang, Gardener, Huppert, & Melzer, 2007). Strandberg et al. observed that the highest alcohol consumption was associated with worse QOL, and moderate alcohol consumption offered no special benefits compared with abstinence (Strandberg, Strandberg, Salomaa, Pitkala, & Miettinen, 2004). Plaisted et al. suggested that the combined fruits and vegetables diet improved HRQOL (Plaisted, Lin, Ard, McClure, & Svetkey, 1999). However, the relationship between QOL and car driving, motorcycle riding, betel but chewing, teeth brushing, and milk consumption remains unknown. In general, most existent literature evaluated the association between health status and HRQOL rather than generic and age-specific QOL. However, QOL is different from HRQOL. HRQOL mainly equates to impairment and disability and is just one of the contributors to generic QOL (Doward & McKenna, 2004). By contrast, life derives its quality from the ability of people to satisfy certain human needs. QOL is good when most needs are fulfilled and is a reflection of the way in which the older people perceive and react to their health status and to other non-medical aspects of their lives (Doward & McKenna, 2004). QOL goes beyond the impairment disability handicap continuum assessed by the HRQOL measurements (Tennant & McKenna, 1995).
549
The value of assessing QOL in addition to HRQOL should never be overlooked (Bradley, 2001). To obtain a complete picture of the impact of clinical conditions, it is essential to measure generic QOL (Doward & McKenna, 2004). Focusing on HRQOL alone might be insufficient. The relationship between the physiological laboratory measurements and generic QOL is little documented. This is the first extensive study of the relationship between routine laboratory tests, lifestyle and generic QOL. We aimed to analyze the relationship between various clinical conditions and lifestyle factors and generic QOL in old age, using the CASP-19 (control, autonomy, self-realization, pleasure) questionnaire. Our theoretical frame is that through the impact on overall bio psycho socio cultural functioning, the poor laboratory test results would be inversely while healthy lifestyles are positively associated with QOL in old age, as shown in Figure 1. Methods We conducted a hospital-based, cross-sectional study in the year 2010. Each year, the Taipei City Government provides a free health examination to all the residents aged over 65 and to native Taiwanese over 55 years. Our population of interest was community dwelling senior citizens in the Taipei City, Taiwan. Eligible candidates were health examinees from a city hospital. Exclusion criteria included inability to provide reliable data, cognitive impairment and difficulty communicating face to face. This city hospital is where the first author and the only research assistant work and is located in one of the wealthiest living areas of the capital. We wish we could enroll more hospitals. However, since this was a smallscale study with limited funding and scarce human resource at the beginning, we were not able to do so. A total of 3680 health examinees were identified. Onefifth of those examinees were randomly selected for questionnaire interview by drawing lots. The interview took place in the same morning right after the health exam. Refusal rate of the older people we approached was roughly 30% 40%. Informed consents were obtained from those who agreed to participate. The study was approved by the Institutional Review Board of the Taipei City Hospital [TCHIRB-990204]. We chose our parameters based on the health examination and questionnaire items, which consisted of collection of general demographic and lifestyle data, physical examination and blood, urine and stool tests. Self-reported lifestyle factors included tobacco smoking, alcohol consumption, betel nut chewing, teeth brushing, milk consumption, intake of fruits and vegetables, regular exercise and motorcycle riding or car driving. Alcohol consumption was classified as no drinking, social drinking or habitual drinking. Exercise habit was classified as no exercise, occasional exercise or regular exercise three to five times weekly. Body stature measurements were based on the national guidelines. The body mass index (BMI, kg/m2) cut-off values for underweight, normo-weight, overweight, mild obesity and moderate to severe obesity were 18.5, 24, 27 and 30, respectively. Central obesity was
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T.-Y. Wu et al.
Figure 1. Theoretical framework of this study.
defined as abdominal girth 80 cm and 90 cm in females and males, respectively. Blood tests included complete blood count and biochemistry profile (blood sugar, liver function, kidney function, lipid profile). Certain enrollees were further tested for serum vitamin D (25-hydroxyvitamin D), lowdensity lipoprotein, thyroid stimulating hormone, a fetoprotein, prostate specific antigen levels and bone mineral density. Samples were analyzed in the core laboratories of the Taipei City Hospital. The bone mineral density was measured by dual energy X-ray absorptiometry (Hologic Explorer QDR, USA). Osteoporosis was defined as T score ¡2.5. An interviewer-administered questionnaire assessed longstanding illnesses and generic QOL, using the CASP19 scale. CASP-19 is a 19-item Likert-scaled index of generic QOL at older ages, which intended to be independent of its main predictors such as health (Netuveli et al., 2006). CASP-19 accesses the domains ‘control (C)’, ‘autonomy (A)’, ‘self-realization (S)’ and ‘pleasure (P)’ (Blane et al., 2008). Control is the ability to actively intervene in one’s environment. Autonomy is freedom from interference from the others. Pleasure and self-realization are the active and reflexive processes of being human (Hyde, Wiggins, Higgs, & Blane, 2003). Higher scores corresponded to a better QOL. CASP-19 has been used in many major international studies. CASP-19 Chinese Taiwan version is a validated standard instrument (Wu et al., 2013). The five-factor model of CASP-19 we proposed has varied items in each domain (2, 2, 5, 6 and 4 items for control, autonomy, self-realization, pleasure and participation, respectively), which makes comparison between domain scores difficult. Also to facilitate international
comparison, we choose to use the original four-factor model in this study. Chronic condition assessment was based on history of 28 common diseases. Polypharmacy was defined as concomitant use of more than four drugs. Self-reported loss of body height was defined as a greater than 3 cm decrease in stature after the age of 40. All analyses were performed using SPSS 14.0 Chinese version (SPSS Inc., Chicago, IBM Company, USA). We dichotomized participants into subgroups according to their laboratory test results (normal vs. above or below reference range, with values provided by the laboratory). This dichotomization based on clinical significance is a common daily practice. Missing data were typically 1 PPD Current drinking No Social Habitual Current betel nut chewing No Yes
N
%
25 344 206 82 25
3.7 50.4 30.2 12.0 3.7
417 266
61.1 38.9
627 28 21 7
91.8 4.1 3.1 1.0
509 156 18
74.5 22.8 2.6
677 6
99.1 0.9
Lifestyle factors Teeth brushing No Once a day Twice a day three times a day Fruits and vegetables everydaya No Yes Milk everyday No Yes Exercise habit No Occasional Regular Driving or riding None Car driving Motorcycle riding
N
%
7 53 382 241
1.0 7.8 55.9 35.3
160 523
23.4 76.6
291 392
42.6 57.4
40 209 434
5.9 30.6 63.5
575 77 31
84.2 11.3 4.5
a
Taking two portions of fruits and three portions of vegetables every day.
driving habits. There were significant differences in QOL among participants as grouped by their age and gender, drinking habit, exercise habit, and riding/driving habit (all p < 0.001). The younger male group had the highest CASP-19 scores as compared to their older or female counterparts. Social drinkers, those who exercised regularly and drivers had the best QOL. The control and the pleasure were the domains with the lowest and highest summated scores (8.4 and 11.8, respectively; p < 0.001). Post hoc analysis revealed that the differences in QOL domain scores existed between younger male group and the rest, older and younger females, social drinkers and
Figure 2. Distribution of CASP-19 total score of the participants.
non-drinkers, non-exercisers and the rest, and drivers and the rest.
Discussion We observed that the advanced age, female gender, blurred vision, certain chronic conditions (depression, rheumatoid arthritis, Parkinson’s disease, and malignancy), anemia, central obesity and motorcycle riding were associated with a lower generic QOL, whereas social drinking, regular exercise and car driving were associated with a higher generic QOL in old age. The total score of the CASP scale differed significantly among subgroups of participants in terms of age and gender. Tsai et al. reported that in Taiwan, the rural elderly women had the poorest HRQOL (Tsai, Chi, Lee, & Chou, 2004). Our findings that men in early old age had the best QOL is consistent with this observation. In the traditional Chinese culture, women’s social position was lower than men’s. This may be the reason for our findings. Steptoe et al. have suggested that positive psychological well-being has biological correlates that may be health protective (Steptoe, Demakakos, de Oliveira, & Wardle, 2012). To our surprise, all laboratory measurements were not associated with generic QOL, except for anemia. By contrast, certain self-reported longstanding illnesses had negative impacts on QOL. As functional limitation is the key dimension of health in its relationship with QOL (Gunaydin, Karatepe, Kaya, & Ulutas, 2011), it is the impact of disease on social functioning that influences QOL rather than the laboratory results by themselves. Poor objective measurements may not equate to poor QOL.
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Table 3. Laboratory test results of the participants and the CASP-19 total score (n D 699). Presenta
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Characteristics Blood tests Anemia (hemoglobin 42 U/L) Renal insufficiency (BUN 24 mg/dL or Cr 1.3 mg/dL) Preprandial hyperglycemia (>100 mg/dL) Hypercholesterolemia (>200 mg/dL) Hypertriglyceridemia (150 mg/dL) High LDL (>130 mg/dL) (n D 214) Hyperthyroidism (5 m units/mL) (n D 251) Elevated AFP (10 mg/L) (n D 251) Elevated PSA (5 ng/mL) (males only) (n D 218) Vitamin D deficiency (
