KRISTIN HANSEN: Health-related quality of life in vulnerable older adults, and implications for priority setting and decision-making

Project description

Background 

The oldest old has become the fastest growing segment of the population, with an increased need of care and social support, in Sweden and globally. With older age, some experience vulnerability which arises partly as a consequence of biological ageing, in which several physiological systems gradually weaken, but also due to chronic diseases. Additional burden arises from polypharmacy (often defined as treatment with >5 medications), advanced age and cognitive impairment leading to increased vulnerability. Frailty is a geriatric syndrome characterized by reduced physiological reserve, with manifestations such as sarcopenia, reduced functional capacity with slower movements, and impaired recovery from temporary illness. Thus, vulnerability is a broader concept than frailty, although the concepts overlap. 

Preventive interventions may counteract the development of frailty [1]. Nevertheless, many older adults will experience vulnerability in later part of life. Interventions to identify those at greatest risk of hospital admission and thereby prevent unnecessary and/or harmful overtreatment are being tested in research and clinical setting [2]. For individuals at risk, comprehensive geriatric assessment (CGA) and person-centred, individualized care can contribute to improved quality of life and reduced unnecessary hospitalizations. For the oldest old, interventions that strengthen and maintain quality of life is preferred over life-prolonging measures [2, 3] using a holistic approach and considering de-prescribing and discontinuation of intervention of less value [4]. 

Health-related quality of life (HRQOL) refers to aspects of an individual’s subjective well-being that are directly affected by physical health, mental state, degree of independence, social functioning, ability to perform activities of daily living, in relation to disease and treatment [5]. HRQOL is a central concept in health economic evaluation and is used in research and healthcare to evaluate treatment outcomes and guide decision-making regarding healthcare interventions. Examples of validated, quantifiable instruments include EQ-5D (EuroQoL 5 Dimensions) and EQ VAS, SF-36 (Short Form Health Survey), and the shorter version SF-6D [6]. 

HRQOL declines with older age but is primarily negatively correlated with frailty and multimorbidity [4, 7-10]. However, comprehensive knowledge regarding HRQOL is limited among older adults, especially in vulnerable older adults. 

Aim

The overall aim of this thesis is to explore and describe health-related quality of life (HRQOL) in vulnerable older adults to better understand their needs and factors that affect HRQOL. The aim is further to increase knowledge of HRQOL in relation to decision-making and priority setting for this group. 

Method

Study 1 examines the association between self-rated health, hospital admission, and mortality in a population aged over 75 years with a high risk of hospital admission. 

Study 2 maps health-related quality of life among older adults with vulnerability factors. 

Study 3 explores perceptions of health-related quality of life among older adults with vulnerability and the factors that influence it. 

Study 4 explores the perceptions of health-related quality of life among older adults with vulnerability from the perspective of physicians in decision-making positions (e.g. primary care, emergency departments, hospital wards) and its implications for decisions and priority setting. 

Relevance 

Increased knowledge on self-reported health and health related quality of life among vulnerable older adults, is expected to be relevant for clinical decisionmaking and coordination of care, especially from a primary healthcare perspective.