Factors associated to quality of life in active elderly Fatores associados à qualidade de vida em idosos ativos

OBJECTIVE: To analyze whether quality of life in active, healthy elderly individuals is influenced by functional status and sociodemographic characteristics, as well as psychological parameters. METHODS: Study conducted in a sample of 120 active elderly subjects recruited from two open universities of the third age in the cities of São Paulo and São José dos Campos (Southeastern Brazil) between May 2005 and April 2006. Quality of life was measured using the abbreviated Brazilian version of the World Health Organization Quality of Live (WHOQOL-bref) questionnaire. Sociodemographic, clinical and functional variables were measured through crossculturally validated assessments by the Mini Mental State Examination, Geriatric Depression Scale, Functional Reach, One-Leg Balance Test, Timed Up and Go Test, Six-Minute Walk Test, Human Activity Profi le and a complementary questionnaire. Simple descriptive analyses, Pearson’s correlation coeffi cient, Student’s t-test for non-related samples, analyses of variance, linear regression analyses and variance infl ation factor were performed. The signifi cance level for all statistical tests was set at 0.05. RESULTS: Linear regression analysis showed an independent correlation without colinearity between depressive symptoms measured by the Geriatric Depression Scale and four domains of the WHOQOL-bref. Not having a conjugal life implied greater perception in the social domain; developing leisure activities and having an income over fi ve minimum wages implied greater perception in the environment domain. CONCLUSIONS: Functional status had no infl uence on the Quality of Life variable in the analysis models in active elderly. In contrast, psychological factors, as assessed by the Geriatric Depression Scale, and sociodemographic characteristics, such as marital status, income and leisure activities, had an impact on quality of life. DESCRIPTORS: Aged. Quality of Life. Life Style. Health Status. Socioeconomic Factors. 614 Quality of life in active elderly Alexandre TS et al The proportion of people over 60 years of age has been growing more than any other age group since the 1970s. This is especially true in developing countries where the elderly is expected to reach 67% of the population by 2020.23 According to the United Nations projections for Latin America, with a projected population of 191 million by 2009, comprising 18 million elderly people, Brazil will have the fi fth largest elderly population among 192 countries.a Health promotion policies for encouraging the elderly to remain active and independent and that effectively have a positive effect on their quality of life is a concern for countries going through this demographic transition. According to the World Health Organization (WHO), remaining active means maintaining one’s physical, social, and mental potential throughout the entire life cycle, allowing the involvement of the elderly in social, RESUMO OBJETIVO: Analisar se a qualidade de vida de idosos ativos e saudáveis pode ser infl uenciada por estado funcional, características sociodemográfi cas e por parâmetros psicológicos. MÉTODOS: Estudo com amostra de 120 idosos ativos participantes de duas universidades abertas à terceira idade, nas cidades de São Paulo e São José dos Campos (SP), entre 2005 e 2006. A qualidade de vida foi mensurada utilizando a versão brasileira e reduzida do World Health Organization Quality Of Life (WHOQOL-bref). As variáveis sociodemográfi cas, clínicas e funcionais foram medidas por meio do Mini Mental State Examination, Geriatric Depression Scale, Functional Reach, One Leg Balance Test, Timed Up and Go Test, SixMinute Walking Test, Human Activity Profi le e questionário complementar. Foi realizada a análise descritiva simples, o coefi ciente de correlação de Pearson, o teste T para amostras não relacionadas, a análise de variância, a análise de regressão linear e o cálculo do fator de infl ação da variância. O nível de signifi cância para todos os testes foi fi xado em 0,05. RESULTADOS: A análise de regressão linear mostrou relação independente e sem colinearidade entre os quatro domínios do WHOQOL-bref e sintomas depressivos avaliados pela Geriatric Depression Scale. Não possuir vida conjugal implicou melhor percepção no domínio social; desenvolver atividades de lazer e possuir renda superior a cinco salários mínimos implicou melhor percepção no domínio meio ambiente. CONCLUSÕES: O estado funcional não foi capaz de influenciar o comportamento da variável qualidade de vida nos modelos de análise em idosos ativos, ao contrário dos fatores psicológicos avaliados pela Geriatric Depression Scale e das características sociodemográfi cas como estado civil, renda e prática de atividades de lazer. DESCRITORES: Idoso. Qualidade de Vida. Estilo de Vida. Nível de Saúde. Fatores Socioeconômicos.

The proportion of people over 60 years of age has been growing more than any other age group since the 1970s.This is especially true in developing countries where the elderly is expected to reach 67% of the population by 2020. 23According to the United Nations projections for Latin America, with a projected population of 191 million by 2009, comprising 18 million elderly people, Brazil will have the fi fth largest elderly population among 192 countries.a Health promotion policies for encouraging the elderly to remain active and independent and that effectively have a positive effect on their quality of life is a concern for countries going through this demographic transition.According to the World Health Organization (WHO), remaining active means maintaining one's physical, social, and mental potential throughout the entire life cycle, allowing the involvement of the elderly in social, RESUMO OBJETIVO: Analisar se a qualidade de vida de idosos ativos e saudáveis pode ser infl uenciada por estado funcional, características sociodemográfi cas e por parâmetros psicológicos.

INTRODUCTION
a Instituto Brasileiro de Geografi a e Estatística.Resultado Censo 2000 [Internet].Rio de Janeiro, 2000 [cited 2005 May 14].Available from: http://www.ibge.gov.br/series_estatisticas/exibedados.php?idnivel=BR&idserie=POP300 economic, cultural, spiritual, and civic activities. 23tively aging is related to a satisfactory perception individuals have regarding their position in life within a cultural background and value system in which they live as well as to their goals, expectations and social standards.Quality of life represents an individual's responses to physical (objective) and mental (subjective) factors that contribute toward a "normal" life, permeated with personal satisfaction, self-esteem, comparisons to others, previous experiences, fi nancial situation, general health status and emotional state. 9terminants in active aging involve complex systems of health promotion and disease prevention, as well as behavioral (e.g., physical activity), psychological (cognitive impairment and depression), environmental (architectonic barriers and access to transportation), and economic factors (income, employment and access to medications).Other determinants include the ability to perform basic and instrumental activities of daily living and the number of comorbidities. 23Among this set of factors, those of economic order are fundamental to the promotion of physical health and education throughout life.Education also promotes a better quality of life as it provides intellectual development and social adaptation.It is assumed that educational programs offered by universities open to senior citizens favor a social support network with family members and friends; motivate the search for information and social interaction; and facilitate intellectual development and a large part of the prerequisites for active aging. 14Such programs are therefore attended by autonomous and independent elderly individuals who differ from the general elderly population in the community in that they represent the concept of active aging as proposed by the WHO.
The aim of the present study was to investigate whether quality of life in active, healthy elderly individuals is infl uenced by functional status and sociodemographic characteristics, as well as psychological parameters.

METHODS
An analytical cross-sectional study was carried out in a sample of 120 subjects over 60 years of age, both males and females, attending two open universities of the third age in the cities of São Paulo and São José dos Campos, Southeastern Brazil.Individuals with independent mobility regardless gaitassistance devices were included in the study.The following were the exclusion criteria: locomotion by exclusive means of a wheelchair; inability to answer the assessment questionnaires due to serious hearing problems or severe communication disorders; unstable angina or acute myocardial infarction within one month prior to the tests, and verbal or written refusal to participate in the study after clarifi cation and reading of the consent form.No one met the exclusion criteria at the two universities studied.
Data were collected by means of questionnaires and performance tests at a rehabilitation center in São Paulo, affi liated to the local university, and at the campus of the open university of the third age in São José dos Campos, from May 2005 to April 2006.A structured questionnaire was applied to collect sociodemographic and clinical data, such as age, gender, marital status, family arrangement, schooling, social security status, occupation, housing condition, personal income, reason for seeking the university, leisure activities, self-reported comorbidities, subjective perception of vision and hearing abilities, falls in the previous year, use of medications, body mass index (BMI) and engagement in physical activity.The cut-off values used for BMI followed the recommendation by Lipschitz 13 for the elderly population: low weight BMI<22 kg/m 2 ; normal weight 22≤BMI<27 kg/m 2 , and overweight ≥27 kg/m 2 .
The Mini Mental State Examination (MMSE) was used in the assessment of cognitive state.The Brazilian version of the 30-item Geriatric Depression Scale (GDS) was used, with a cut-off value of 11 or more symptoms of depression, based on the recommendation by Yesavage, who found 84% sensitivity and 95% specifi city. 25e Visual Analogue Scale (VAS) was employed for pain assessment.Functional exercise capacity was assessed using the Six-Minute Walk Test. 2 Mobility was assessed by the Timed Up and Go Test (TUGT), 15 with the following normal ranges for healthy elderly individuals in different age groups: 7.1 to 9.0 seconds for those between 60 and 69 years, 8.2 to 10.2 seconds for those between 70 and 79 years; and 10.0 to 12.7 for those between 80 and 99 years. 3Balance was assessed using the Functional Reach 8 and One-Leg Balance Test. 22Functional capacity was assessed by the Brazilian version of the Human Activity Profi le (HAP), which has items that are diffi cult enough to determine high levels of capacity or functional performance, thereby minimizing the ceiling effect commonly seen in other functional assessment scales by assessing the individual's functional level as well as the level of physical activity. 20e World Health Organization Quality Of Lifebref (WHOQOL), 11 an abbreviated version of the WHOQOL-100, was used for the assessment of quality of life domains.The WHOQOL-bref consists of 26 items -two on overall quality of life and 24 representing four domains: physical, psychological, social relationships, and environment.
The power of the sample to detect errors was of up to 8.9% when the proportions estimated 0.5 for significance level and 95% for confi dence intervals.Simple descriptive analysis was used.Pearson's correlation coeffi cient (r ≥0.3) was used to identify the degree of association between quantitative variables.The Student's t-test for non-related samples was used to determine the degree of association between dependent variables (quantitative) and qualitative variables.Analysis of variance (ANOVA) was employed for qualitative variables with three or more categories.Multiple linear regression was used to identify independent associations after the preliminary analysis.The signifi cance level for all statistical tests was set at 0.05.The variance infl ation factor was also estimated.
The study was approved by Research Ethics Committee at the Universidade Federal de São Paulo.

RESULTS
The sample was characterized by a female majority (85.8%) with mean age of 69 years (standard deviation [SD]=5), ranging between 60 and 89 years old.Most elderly had a conjugal life (39.2%);among those who did not have a conjugal life, 38.3% were widowed.Subjects had an average of 9.94 years of schooling (SD=4.93);24.2% of them had university education.There were no illiterate subjects in the sample, as literacy is a prerequisite for enrolment at the open university.In regard to the family structure, 69.3% resided with family members.The average monthly income was US$ 687.76 (SD=601.66),55.8% of the elderly subjects interviewed had health insurance and 80.8% were homeowners.
The study subjects reported having sought the university for reasons of occupying their free time and socialization (55.8%), intellectual improvement (28.3%), or to address a health or family-related problem (15.8%).When asked about leisure, 92.5% engaged in leisure activities and 66.7% in trips and social activities.There was a preference for group (48.3%) and outdoor activities (56.7%).
The average number of reported comorbidities was 5.62 illnesses (SD=2.96).Dyslipidemia was the most prevalent condition (49.2%), followed by systemic arterial hypertension (46.7%), peripheral venous insuffi ciency (45.8%), and osteoarthritis (39.2%).Seventy-fi ve per cent had osteoarticular pain, showing an average of 2.47 centimeters on the pain visual analogue scale.Only one elderly subject was a smoker (0.8% of the sample).Only 11.7% of the elderly studied reported having been hospitalized in the previous six months and 85.8% made use of medications.
Vision and hearing abilities were self-reported as "good" or "excellent" by 70.8% and 65% of the elderly, respectively.Twenty-eight per cent of the subjects had suffered falls in the previous six months, 49.2% reported fear of falling and 1.7% made use of gait assistive devices.
Mean BMI of the elderly studied was 27.06 kg/m 2 (SD=4.86).Forty-four per cent were classified as overweight and 13.3% were low weight.Of all, 67.5% engaged in physical activity, 41.7% engaged in physical activities from one to four times per week, with duration of thirty minutes to one hour per session.
On the Functional Reach scale, subjects showed an average of 27.27 centimeters (SD=4.97).Seventy-one per cent of them managed to perform the One-Leg Balance Test.
In the TUGT mobility assessment, subjects performed the task in an average of 8.10 seconds (SD=1.62)and 99.2% performed it within 13.5 seconds.
On the Six-Minute Walk Test for assessing functional exercise capacity, the average distance covered was 477.68 meters (SD=65.05).
According to the HAP, 88.3% of the elderly subjects were classifi ed as "above average".With respect to physical activity, 81.7% were classifi ed as "moderately active" and 7.5% as "active".The HAP score indicated that 70% of the elderly were "better than the chronological age".
Not having a conjugal life was associated to better performance in the social relationships domain of the WHOQOL-bref questionnaire.Living alone, having a personal income of more than fi ve monthly minimum wages, having health insurance and engaging in leisure activities were associated to better performance in the environment domain of the WHOQOL-bref questionnaire as show in Table 1.
Self-reported vision and hearing classifi ed as "good" or "excellent" was associated to better performance in the environment domain of the WHOQOL-bref questionnaire.Engaging in physical activities was associated to the physical domain of the WHOQOL-bref; subjects who engaged in physical activities fi ve or more times per week scored higher in this domain.Having reported suffering a fall in the previous six months was associated to worse performance in the physical domain of the WHOQOL-bref.Those who reported having fear of falling scored lower in the psychological and environment domains as shown in Table 2.
The elderly who were classifi ed as "above average" showed better performance in the physical and environment domains of the WHOQOL-bref.The subjects showing the best performance in the physical, psychological, social, and environment domains of the WHOQOL-bref were those classifi ed as "better than chronological age" based on HAP (Table 3).In addition, Table 3 shows the average scores on the WHOQOL-bref questionnaire according to functional variables.
For the multiple linear regression analysis the clinical variable "frequency of physical activity" was recategorized before grouping the remaining variables in the statistical procedure.
The variance infl ation factor was estimated to exclude the possibility of overlapping of highly-correlated independent variables.Values between 0.19 and 5.30 denote no colinearity between the variables in the regression model.Table 4 displays the results of the independent correlations for each domain regarding quality of life of active elderly.

DISCUSSION
The WHO has promoted a process of optimizing opportunities for health, participation and security among the elderly with the aim of improving their quality of life. 23ased on our fi ndings, we may infer that the population studied fulfi ls the criteria for the classifi cation of active elderly individuals.
The presence of illness may impair the perception of health and quality of life of the elderly.However, these same individuals may be considered healthy, even if they have chronic, degenerative, but controlled diseases.Among active elderly subjects studied, there was an average of 5.62 self-reported comorbidities, a fi nding that is consistent with that of a population-based study carried out in São Paulo. 16Despite this considerable number of comorbidities, most of the elderly subjects analyzed were considered either moderately active (81.7%) or active (7.5%) from a functional perspective, as assessed by the HAP.We can suggest a plausible reason for this fact if we consider that health is a good indicator of negative quality of life, but it may be insuffi cient indication of successful aging. 24ese elderly individuals had good mobility, similar to that found by Bohannon in the evaluation of healthy elderly (60 to 69 years of age) with performance ranging from 7.1 to 9.0 seconds. 3This fact is also important for it is lower than the cutoff value of 13.5 seconds adopted by Shumway-Cook et al as a risk for falls in the upcoming year. 19As such, the elderly subjects in the present study are theoretically clear of this event, which is directly related to morbidity.
Good mobility was refl ected in the results of the functional exercise capacity.Troosters et al 21 showed that elderly individuals free of chronic degenerative diseases and with no history of hospital admission walked an average of 631 meters.However, age, gender, and BMI impaired performance in this test.Though elderly in the present study had lower performance (477 m) when compared to the elderly subjects studied by Troosters et al, they were older, mostly females, and had a greater number of self-reported chronic degenerative disease and higher mean BMI.
Not having a conjugal life, having higher schooling (24.2% of subjects had university education) and having an average monthly income of US$ 687.76 favored a positive perception of quality of life.An income greater than fi ve minimum wages was associated to better performance in the environment domain of quality of life.Schooling contributed toward a greater income, which can ensure better health at advanced ages.Healthy lifestyles are common among groups with higher income as they have greater knowledge on disease prevention; have healthier habits throughout their lives; and have greater access to health services by means of private health plans. 17better fi nancial situation also favors greater autonomy in the choice of leisure activities, increased access to goods and services, relationships and, especially, family arrangements.An individual who is not dependent can choose to live alone, thereby exercising his/her independence and privacy without giving up contact with family members.Another option would be to live in a multi-generation household, thereby participating in raising grandchildren and in the family income. 4This context implies a situation of security, allowing elderly individuals to remain active and socially involved.
According to a review by Peel et al 14   According to Xavier et al, 24 having good health, good family relationships, fi nancial security, friends and work ability are determinants of good quality of life.
Not having a conjugal life was a preponderant factor for a better quality of life in the social relationships domain.
In a pioneering study on successful aging Rohe & Kahn 18 reported that lack of social network support, whether from their spouse, family or social groups, may increase morbidity and mortality rates in older population.
The predominance of widowed women in the sample could be the key to this issue.Fernandez-Ballesteros et al 10 analyzed the contribution of sociodemographic and psychosocial factors to life satisfaction among the elderly and found that married women were more satisfi ed than widowed, single or divorced women.Also, the level of satisfaction among married women was associated to higher income and schooling, physical and leisure activities, and having a better social life and health.The present study showed similar factors associated to a better perception of health in active elderly women but it contrasted with regard to marital status.
In Brazil, however, there are anthropological and social factors that can explain the differences between the data found in our study and those from other studies.If we consider that most elderly Brazilian women did not have paid jobs during their entire lives, were not selfsuffi cient during their youth and adult life and depended on their spouses, widowhood can means autonomy and independence from both the fi nancial and social standpoints.One additional contributing factor is the widowhood pension they receive, which is proportional to the last benefi ts due to their spouse, that combined with their retirement pension generates a higher income for these elderly women. 7The Quality of life and depression measures have distinct evaluative capabilities; GDS assesses the presence or not of a particular factor indicative a depression symptom, whereas the WHOQOL-bref assesses the intensity of an effect or level of satisfaction in a particular situation and the impact on quality of life.Therefore, the WHOQOL-bref should be used in combination with an assessment of depression symptoms to determine whether a quality of life measure is biased by such symptoms before prematurely coming to any conclusions regarding the quality of life of any individual. 1n the present study, the scores indicative of potential depression cases were low and the variance infl ation factor revealed that there was no colinearity between the WHOQOL-bref and GDS.This indicates the need to apply the GDS to active elderly individuals as the presence of depression may have a signifi cant negative effect on their quality of life.
Although the WHOQOL-bref has adequate psychometric properties for the elderly population, as Chachamovich et al 5 showed, the instrument does not address some important aspects the elderly individuals reported as having an infl uence on their quality of life such as relationships with family members, motor or sensory losses that limit their daily activities, spirituality and social participation.The fi rst two aspects are assessed in the WHOQOL-bref, but only indirectly by addressing the relationship with friends, relatives, acquaintances and locomotion, whereas the third and fourth aspects are not addressed at all.The WHOQOL group recognizes the limitations of their instrument in the assessment of quality of life of the elderly and has therefore developed the WHOQOL-OLD.It is a complementary instrument to either the WHOQOLbref or the WHOQOL-100, with 24 Likert scale items addressing the following six components: sensory functioning; autonomy; past, present and future activities; social participation; death and dying; and intimacy. 6,12he WHOQOL-OLD was not used in the present study for it was not available when the fi eld work began.
As the elderly attending the open university were found to be functionally and cognitively well, fi nancially stable, actively participating in the program and seeking to improve their knowledge, they can be considered representative of active aging.Depression symptoms, however, can disrupt this harmonious cycle.Early diagnosis and treatment of depression is therefore of vital importance, as well as evaluations of a multidisciplinary team, in order to keep them on the path of functionality and good quality of life.
It is thus important to investigate other groups of elderly that belong to senior citizen centers, sports centers for the elderly and active elderly in the community in an attempt to assess similarities and differences in the infl uence of objective factors such as functional status, as well as sociodemographic characteristics and psychological factors on the quality of life of these populations.Further studies can provide more input to the planning of public policies that can help improve the quality of life of a much larger proportion of elderly population.

Table 1 .
Average scores on the WHOQOL-bref questionnaire according to sociodemographic variables in 120 active elderly individuals.Cities of São Paulo and São José dos Campos, Southeastern Brazil, 2005-2006.

Table 4 .
Final model of the linear regression analysis for each quality of life domain in active elderly subjects.Cities of São Paulo and São José dos Campos, Southeastern Brazil, 2005-2006.(N=120)