Quality of Life in Older Adults Receiving Long-Term Services and Supports: Is It What We Think It Is?

Abstract

article that investigated quality of life and preferences for lifesustaining treatment. They found that physicians rated patients’ global quality of life, physical comfort, depression, and function significantly worse than did the patients themselves. As greater numbers of older persons are facing the need for long-term services and supports (LTSS), and with the national focus to “rebalance” these services out of nursing home settings and back to the community, it is important to understand factors that support the domains that determine health-related quality of life (HRQoL). Consistent with past research, Naylor and colleagues, 2 in this issue of JAMDA, found that several HRQoL domains (high physical function, emotional well-being, fewer depressive symptoms, and greater social support) were strongly associated with higher quality-of-life ratings, 2 but several surprise findings seem to go against some of our long-held assumptions. First, this study reported the average quality-of-life ratings were higher among those with increased deficits in activities of daily living. Second, quality-of-life ratings were higher for those receiving LTSS from assisted living settings when compared with nursing homes or home care. Finally, those individuals who had fewer cognitive deficits in their quality of life improved over time when they received LTSS. Social isolation has been identified as a risk factor for hospitalization and mortality. 3e5 We know that social isolation is associated with depression and functional decline. Sara Hann Qualls, PhD, summarized this concept of the negative effects of social isolation by saying, “The social portion of the bio-psychosocial model may be the next frontier for targeted intervention to improve health across the lifespan, with direct impact on the experience of aging.” 6 Perhaps the common link among the 3 groups with unexpectedly higher quality-of-life scores (increased needed supports in activities of daily living, those in assisted living facilities compared with home care, and those who were receiving LTSS over time) was that each, potentially, had an increased support system that involved the engagement with others focused on their well-being. And conversely, perhaps the greatest risk of lower quality of life would be those older persons who live alone in the community and receive no forms of social support, either through their own systems of personal engagement, or through the connections provided through LTSS. As we approach family and patient discussions regarding the need for LTSS, it is important to think about our own biases as we help seniors and their families navigate through difficult decisions. Having areas of dependency and support needs does not mean a lower quality of life. Living alone at home, although often expressed as the goal for many older people, may not support the sense of well-being or how they would rate their quality of life. Last, perhaps some of the benefits of Home and Community Based Services, such as adult day services, low-income housing with services, and nonmedical home care, go beyond the specific functional supports delivered; they all provide that common thread of personalized social engagement that links one human to another. As Mother Teresa said, “The most terrible poverty is loneliness, and the feeling of being unloved.” Perhaps addressing social isolation in our strategies to design LTSS models is the right place to start for care planning, for housing decisions, and for public policy.