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3
Health Status and Quality of Life
As individuals age, they are at risk for diseases and disabling con-
ditions, use more medical care services, and incur medical expenses.
While there is no doubt that age is a predictor of morbidity and mor-
taTity, its predictive value is limited. The health status of the elderly
is better than generally assumed, varies remarkably among individu-
als, and is changing as successive cohorts progressively challenge the
definition of old age.
One major misconception in the health care field is that the el-
derly are a homogeneous group of frail individuals progressing rapidly
toward needs for long-term care. The elderly actually are a very het-
erogeneous group. It has been noted that as individuals age, they
become less like each other (Rowe, 1985~. From a physiological per-
spective, differences between individuals characteristically increase
with advancing age in those factors that change with age, such as
blood glucose level and blood pressure. From a clinical perspective,
specific subgroups of elderly individuals can be identified, including
the 5 percent who at any one time are residing in long-term care
facilities and the larger portion who have major functional declines.
The marked effect of age itself on disability, morbidity, and mortality
has led many workers in the field to divide the overall elderly popula-
tion into at least two groups, a young-old population and an old-old
population, which is characterized by frailty and marked increases
in the need for acute and long-term care services (Besdine, 1982~.
These clear age-related differences suggest the value of collecting dif-
ferent types of data in different age subsets. The pane] has chosen
65
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66
AGING POPULATION IN THE TWENTY-FIRST CENTURY
to use three age subsets: young-old (age 65-74), old (age 75-84), and
oldest-old (age 85 and older).
The health care of elderly persons, perhaps more than any other
age group, IS influenced by the social support system available to
them (Brady, 1981~. The network of current and potential informal
supports, such as family or friends, has an important role in modu-
lating the clinical impact of underlying disease and is often the major
determinant in decisions to institutionalize elderly people. For every
impaired elderly person in a nursing home, there are approximately
two equally impaired elderly people living in the community who of-
ten can remain there by virtue of the critical role of informal support
systems, which provide approximately 80 percent of their Tong-term
care (Doty, 1986~.
In choosing which data need to be collected and how they should
be analyzed, it is important to recognize that the needs of the elderly
differ from those of younger individuals, not only from a quantitative
perspective (i.e., the elderly use more health care services), but also
qualitatively. "Just as children are not merely young versions of
adults, the elderly are not simply old adults. They require special
approaches" (Rowe, 1985:827) and their health care needs reflect
a complex interaction of the physiologic changes with age, their
psychosocial concomitants, and the various pathologic processes that
occur with advancing frequency in senescence.
Although health status per se is not a policy issue, policy analysts
need to be able to detect trends and to forecast changes among the
elderly in their health status and utilization of services. Development
of such trend data requires a stable program of periodic surveys of
the health status of the elderly population.
This chapter reviews and summarizes what is known about the
elderly and the aging process in the later years with respect to health
status, functional status, and quality of life and their determinants.
The major sources of statistics relevant to these topics are reviewed
and changes are recommended that will augment the available in-
formation on the health status of the elderly, provide information
to understand the health needs of the elderly, provide a dynamic
description of aging as a process, and lead to improved measures of
functional status of the active elderly that will help trace the transi-
tions from their well state to states of disability as well as measure
their need for assistance. The chapter concludes with a review of the
relationship between health and functional status and the quality
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HEALTH STATUS AND QUALITY OF LIFE
67
of life experienced by the elderly and discusses some of the compo-
nents of quality of life with emphasis on the relationship between
productive activity and quality of life.
HEALTH STATUS
Characteristics of Health Status and Data
Successful Aging
For too long, gerontological research has focused on the Tosses
in function that occur with advancing age. We have lost sight of
the fact that most elderly individuals function very well and report
their health as good or excellent. Despite the physiologic Tosses and
the psychosocial stresses often associated with advanced age, many
elderly individuals have the vitality and resilience to function at a
high level. Data collection should take into account the positive
aspects of aging rather than purely functional decline, disease, and
mortality. Similarly, there needs to be increasing recognition of the
capacity of individuals to Improve over time; thus, data sets should be
conceptualized with a view to following individuals as they increase
in their functioning, rather than only to their entering a pathway
of progressive loss of function leading to disability and ultimate
mortality.
Longevity Extension and Compression of Morbidity
A major policy issue relates to the relationship between changes
in the mortality experience of the elderly population and coincident
changes in the underlying morbidity and disability experiences.
In 1900, a man who reached the age of 65 could expect to live
11 more years, and a woman age 65 could expect to live 12 more
years. By 1984, men turning 65 could expect to live 14.5 more years,
and women turning 65 could expect to live 18.7 more years (National
Center for Health Statistics, 1986c). This Longevity revolution" has
even affected the very old, as the past two decades have brought
dramatic reductions in mortality rates among those over 80, both
men and women.
The important issue, however, is the quality of the additional
years of life for the elderly. Are the additional years ones of vigor
and independence, or of frailty and dependence? Will future in-
creases in longevity be associated with prolongation of dependency
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68
AGING POPULATION IN THE TWENTY-FIRST CENTURY
or will active life expectancy increase (~compression of morbidity")
as health promotion and disease prevention strategies become in-
creasingly effective (Rowe, 19853?
"The initial claim that as mortality declines morbidity will also
decline has recently been challenged by studies suggesting that the
increased life span of the old-old is not accompanied by decreased
morbidity and may actually result in more dramatic increases in
the need for health care services" (Rowe, 1985:828~. While federal
statistics have documented the changes in life epollutantsxpectancy
during the twentieth century, there are no national data showing
whether the period of vitality has also changed. Thus, it is not known
whether either the actual number or the proportion of people's later
years that are spent in a healthy state has increased, remained the
same, or decreased during the period when the life span has increased.
Chapter 4 discusses this issue in detail.
Transitions Tom Morbidity to Disability and Mortality
The World Health Organization has proposed a model (Man-
ton, 1986a) that describes the linkages between mortality, disability'
and morbidity (discussed in detail in Chapter 4~. While it is clear
that the overall mortality experience of the elderly population has
an underlying curve of morbidity experience in which individuals
accumulate diseases and losses in specific capabilities, the specific
interactions between the development of diseases and the subsequent
development of disability have not been elucidated. It is particularly
important to recognize that many different pathologic processes may
result in, or contribute to, identical functional impairments. For any
particular person, several coincident pathologic processes interact in
a complex fashion to result in disability. This interaction is often
strongly influenced by other factors, particularly in the psychosocial
sphere.
The marked variability in health status among the elderly and
the uncertain nature of the link between the presence of pathologi-
cal processes, their functional consequences, and eventual mortality
underlie the importance of an approach to the elderly that permits
analysis of the transitions that individuals make from one functional
status or health state to another. It Is clearly inadequate to fo-
cus only on mortality, hospitalization, or institutionalization as end
points and increasingly important to detect changes in function when
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HEALTH STATUS AND QUALITY OF LIFE
69
they occur and to develop sensitive measures of the severity of dis-
ease processes. It Is particularly important in studies of transitions
in health status to maintain a perspective that permits detection of
improvements over time, rather than just losses in functions.
This approach may be more difficult in elderly patients than
in their younger counterparts because there appears to be a very
short recall period for health interactions in the elderly. In addition,
self-reported data regarding some functional status measures, such
as those referred to as instrumental activities of daily living, may
not be adequate. Studies should be carried out to clarify whether
the inaccuracy of such self-report data is a function of age or age-
associated diseases, such as those that impair cognitive function.
The Need for Acute and Chronic Care
Over the past several years, the dramatic increase in Medicaid
spending for nursing home care has led to a progressive interest in
the long-term care needs of the elderly and to finding alternatives to
high-cost institutionalization. The critical importance of acute care
in the elderly appears to have been underemphasized: more than 40
percent of the health care expenditures of the elderly are for acute
care (Waldo and Lazenby, 1984~. In addition, the common practice
of identifying the type of care given by the site in which it is given
is increasingly misleading. On one hand, many elderly individuals in
acute care facilities receive chronic care. Some are admitted to an
acute care hospital in order to gain access to a long-term care facility,
and some are admitted to a hospital because of a worsening of a
chronic condition. On the other hand, with the implementation of
prospective payment and diagnosis-related groups under Medicare,
there is a tendency for acute care hospitals to discharge patients
to Tong-term care facilities earlier than they did previously. Many
nursing homes are now faced with providing acute care, especially
acute postoperative care, in facilities not designed for this care and
by staffs who are often inadequately trained. In tracking patients'
progress through the health care system, it is bemoaning increasingly
important to know not only the locus in which care is provided, but
also the specific nature of the care.
Determinants of Disease In Old Age
With advancing age, the general tendency is a shift from acute
to chronic diseases. For example, hypertension and coronary heart
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70
AGING POPULATION IN THE TWENTY-FIRST CENTURY
disease increase with age, as does the risk of cancer, autoimmune dis-
eases such as pernicious enema and Addison's disease, and diseases
of the bones and joints such as arthritis and osteoporosis.
The reasons for such increases are not fully understood. Increases
in specific disease categories may reflect increased vulnerability with
age, in turn caused by a wide range of age-related phenomena, from
reduction of the immune functions to Tosses in physical agility. But
age-related increases in pathology do not necessarily imply increased
inherent vulnerability; they can also result from cumulative expo-
sure to environmental pollutants or from reduced resources, both
economic and interpersonal. Per capita income decreases with age,
especially after work and retirement, and the likelihood of personal
loss through bereavement increases, with possible concomitant re-
duction in sources of health-promotive assistance and support.
To the risk-enhancing aspects of old age must be added charac-
teristics or capabilities of the elderly that may decrease risk. Each
successive age group consists by definition of survivors, so there is an
inevitable selection factor at work. Separate from the constitutional
or genetic factors in such selection are the effects of learning. With
increasing age people may be differentially successful in learning to
recognize their own limits, avoid various environmental risk factors
(e.g., quit smoking), or modify the severity of the risk (e.g., smoke
less). Such learning then becomes a counterforce to the age-related
factors that increase risk of disease and death.
Current understanding of these complexities is fragmentary. For
example, some demographic characteristics are known to be associ-
ated with longevity (i.e., negatively related to standardized mortality
ratios), but the causal pathways or the reasons that these relation-
ships become weaker with age is not known. Such reductions in
the older age groups have been observed for education, socioeco-
nomic level of residence, race, and marital status. Some predictive
relationships (e.g., the effect of high blood pressure on mortality
and morbidity and the effect of supportive social ties on the risk of
hospitalization), however, persist throughout the entire age range.
And some relationships (e.g., the effect of marital dissatisfaction on
coronary heart disease) seem to increase with age.
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HEALTH STATUS AND QUALITY OF LIFE
Special Characteristics of niness Behavior in the Elderly*
Underreporting of Health Conditions
71
An important characteristic underlying functional impairment
in the elderly is the failure of many persons to seek assistance despite
the fact that both clear-cut illnesses and abnormalities are present.
Studies in several countries with varying health care systems indicate
that symptoms of serious and treatable diseases often go unreported
(Rowe, 1983; Anderson, 1966~. Health problems reported by frail
elderly persons are thus frequently only the tip of the iceberg of
treatable conditions. As Besdine (1982) pointed out, nonreporting
of symptoms of underlying disease in elderly persons is an especially
dangerous phenomenon when coupled with the passive structure of
American health care delivery, which lacks prevention-oriented or
early detection efforts. He notes that aged persons, burdened by
society's and their own views of functional loss with aging, cannot be
relied on to initiate appropriate health care for themselves, especially
early in the course of an illness.
Multiple Pathology
The coexistence of several diseases has a profoundly negative in-
fluence on health and functional independence in the elderly, and the
number of pathologic conditions in a person is strongly related to age.
Elderly persons who live in the community have on the average three
to four important disabilities (Anderson, 1966), and the hospital-
ized elderly have evidence of six pathologic conditions (Wilson et al.,
1962~. The entire array of diseases present in an individual patient
must be considered as models are developed to describe pathways to
dependency and as treatment plans are developed. Multiple pathol-
ogy has obvious implications for health interview surveys, provider
surveys, hospital discharge records, and the vital statistics on cause
of death.
Atypical or Altered Presentation of Disease
A fundamental principle of geriatric medicine is that many dis-
eases have signs and symptoms in the elderly that differ from those
*This section closely parallels the section on "Illness Behavior in the Elderly"
in Rowe (1985:830~.
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72
AGING POPULATION IN THE TWENTY-FIRST CENTURY
in their younger counterparts. These alterations can take two major
forms. First, specific symptoms characteristic of a disease in middle
age may be replaced by other symptoms in old age. For instance,
in acute myocardial infarction, some studies have suggested that el-
derly persons are less likely than younger adults to have chest pain.
But acute myocardial infarction is not "silent" in older persons, who
have instead a variety of other acute signs and symptoms. The sec-
ond difference is that elderly persons may have nonspecific signs and
symptoms, such as confusion, weakness, weight loss, or "failure to
thrive" instead of specific symptoms indicating the organ or system
affected.
HEALTH DATA
Major Sources of Health Statistics
The United States is fortunate in having well-developed systems
of data collection for demographic, social, and economic character-
istics of the population and for its rates of morbidity and mortality,
health expenditures, and utilization. These data collections are the
major responsibility of two agencies: the Bureau of the Census in
the Department of Commerce and the National Center for Health
Statistics (NCHS) in the Department of Health and Human Services.
Many other agencies collect data directly related to their missions.
The two major agencies produce general-purpose data for pro-
gram and policy decisions and devote a substantial portion of their
staff to serve needs of researchers and policy makers and the general
public. Historically, the programs of the National Center for Health
Statistics have been the major source of information on the health
status of the population. This report, in its discussion of policy is-
sues related to health problems of the elderly, draws on only a small
part of the data available on the health of the U.S. population. The
surveys relevant to this chapter are the National Health and Nutri-
tion Examination Survey and the National Health Interview Survey
and its supplements. A related source of information is the series
of national medical expenditure surveys conducted by the National
Center for Health Services Research ant! Health Care Technology
Assessment in 1977, 1980, and 1987, which are discussed in detail in
Chapters 8 and 9 (on financing and utilization of health services).
Recently a new source of health status information became available
from the Bureau of the Census: in 1984 the Bureau fielded the first
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HEALTH STY TUS AND Q BALI TY OF LIFE
73
wave of the Survey on Income and Program Participation (SIPP),
which includes a topical module on health and disability. Although
health status is not its major focus, SIPP does provide data that can
be used to relate health status to income; SIPP is discussed in detail
in Chapter 10.
The National Health Inter~riew Surrey
The National Health Interview Survey is a principal source of
information on the health of the civilian, noninstitutionalized pop-
ulation of the United States. The survey, conducted continuously
since 1957, provides national data annually on the incidence of acute
illness and accidental injuries, the prevalence of chronic conditions
and impairments, the extent of disability, the utilization of health
care services, and other health-related topics.
The data are obtained from 40,000 household interviews that
include about 110,00C) persons. Of these, 7,500 to 8,500 are ages
65-74, and 4,800 to 5,400 are age 75 and older. Because of budget
constraints the sample size was reduced by 50 percent in 1986. To
provide data on special topic areas in addition to the basic NHIS
data, supplements to the NHIS have been conducted annually for
the past 20 years.
The THIS Supplement on Aging
One of the NHIS supplements is the Supplement on Aging. Con-
ducted in 1984, it is a major source of information on long-term care
services used by the elderly particularly when used in conjunction
with data collected by the I,ongitudinal Study on Aging, described
below. Its purpose was to collect health and community service uti-
lization information on the portion of the 1984 NHIS sample that
was age 55 and over, which could be related back to the information
regularly collected in the NHIS on these respondents. The SOA was
administered to half the persons in the NHIS sample who were age
55-64 at the time of the interview and to all of those then age 65 and
over.
The Longitudinal Study on Aging
The SOA is also the base for the I`ongitudinal Study of Aging,
a prospective study of the same panel interviewed for the SOA. All
respondents will be followed for at least six years by linkage with
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74
AGING POPULATION IN THE TWENTY-FIRST CENTURY
death records through the National Death Index. Respondents age
65 and over will be followed for at least six years by linkage with
Medicare records. Those age 70 and over will be reinterviewed by
telephone. The LSOA, which is based on a sample selected in 1984,
provides extensive data on the health and medical history of a single
cohort of the elderly.
Rapid changes in health, medical care needs, living arrange-
ments, and available support are characteristic of the older popu-
lation. The environment in which these personal changes occur is
also in a constant state of flux. In order to understand the changing
health needs of the older population, a sample should be selected
from a new cohort and should be followed for at least five years-
a plan that would permit measurement of some of the transitions
occurring in the elderly population.
Recommendation 3.1: The pane! recommends that the Na-
tional Health Interview Survey's supplement on aging for
the noninstitutionalized population ages 55 and over be re-
peated every 5 years. The sample should be followed for at
least 5 years, and preferably 10 years, and interviewed for
characteristics relevant to the older population as wed as for
changes in these characteristics.
The follow-up could be carried out by a combination of telephone
calls and personal interviews with varying frequencies appropriate to
the age of the sample member.
The Integrated System of Health Interview Surveys
The NCHS plans to replace the NHIS by 1989 with an Integrated
System of Health Interview Surveys (ISHIS), which, although struc-
turaBy different, will retain many of the attributes of the NHIS. It
should still be possible to implement the panel's recommendations
with the modified structure of the NHIS. The modification provides
for core questions, the ability to link with other data bases, and
surveys of special topics. The sample design consists of four panels,
each a national probability sample of households. Core questions
will be addressed to allfour panels, although core items may be ro-
tated from year to year. Emphasis is placed on the use of screening
questions in the core to identify special subgroups of the population,
e.g., veterans, who might then be followed in a special topic survey.
The modifications also recognize the importance of being able to link
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HEALTH STATUS AND QUALITY OF LIFE
75
NHIS data with other data bases. The National Death Index will be
checked routinely for all surveys to ascertain year and cause of death.
Discussions are under way with the Health Care Financing Admin-
istration concerning the possibility of a follow-on survey of ISHIS
participants to obtain their Medicare history. Provision will be made
to explore special topics of current policy relevance, on request, with
one or more of the panels. These special topic surveys will be funded
externally.
The National Health and Nutrition Nomination Surveys
The National Health and Nutrition Examination Surveys were
established to collect those kinds of health data optimally obtained
by direct physical examinations and physiological and biochemical
measurements. The surveys measure the health and nutritional sta-
tus of the U.S. population and permit estimation of the prevalence
of certain diseases and the distributions of a broad variety of health-
related measurements. NHANES I was conducted from 1971 to 1975;
NHANES II was conducted from 1976 to 1980; current plans are un-
der way for NHANES Ill to be fielded in 1988.
NHANES ~ and NHANES IT did not include persons age 75 and
over because it was anticipated that the logistics of bringing the
frail elderly to the examination site would present serious problems,
and any attempt to do so would result in a poor response rate. The
growth of the older population has made it extremely important that
this group be included in NHANES ITI. Ways must be found to make
it possible to examine elderly people in their homes both to improve
the response rate and to avoid the bias inherent in sampling only
those able to come to the examination site.
Recommendation 3.2: The pane] recommends that the Na-
tional Institute on Aging and the National Center for Health
Statistics support methodological work to increase the par-
ticipation of older people in examination and interview sur-
veys.
Recommendation 3.3: The panel recommends that the sam-
ple for NHANES IT! should not have an age cutoff. The panel
further recommends that the sample of persons age 65 and
over be adequate to provide suitably precise estimates of the
prevalence of specific medical conditions among those over
age 65.
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HEALTH STATUS AND QUALITY OF LIFE
Mental Health E unction
83
In the measurement of mental function, self-reported assessments
are used almost exclusively in this country, where epidemiologic stud-
ies are generally performed by lay interviewers. In contrast, clini-
cians have been involved in studies in Europe, and have therefore
made psychiatric diagnoses as traditionally done in a clinician's of-
fice. Our understanding of some aspects of mental functioning would
be enhanced through the combination of screening procedures and
standardized diagnostic interviews. Standardized measures of morale
and depression that can be used in community surveys are: the Law-
ton Morale Scale, the Center for Epidem~ological Studies-Depression
Scale (CES-D) (Radioff, 1977) designed by the National Institute
of Mental Health (NIMH), and the Beck Depression Scale, among
others. In addition, NIMH has sponsored the development and field
testing of the Diagnostic Interview Schedule (DIS), which approxi-
mates the DSMIT! (Diagnostic and Statistical Manual, ad edition)
categorization of clinical diagnoses and can be administered by lay
interviewers. The DIS was developed for use in the Epidemiological
Catchment Area Projects.
Social Function
For measuring social function, numerous self-reported items are
used in community surveys. The Alameda County Study (Berkman
and Bresiow, 1983) and the National Institute on Aging's Estab-
lished Populations for Epidemiologic Studies of the Elderly project
(Cornoni-Huntley et al., 1986) are two examples.
ABeessing Functional Status
There are numerous functional tests in addition to those dis-
cussed above. Several recent studies have listed and described the
existing tests (Kane and Kane, 1981; Mangen and Peterson, 1982;
Fillenbaum, 1984~. In her study published by the World Health Or-
gar~ization (WHO) in 1984, Fillenbaum argues for a multidimensional
approach to functional status (p.5~:
There have been few attempts to make a comprehensive asness-
ment of the well-being of representative groups of elderly people
as a basis for policy decisions concerning the provision of appro-
priate services. Rather than considering the elderly person as an
integral human being, the tendency of care givers and research
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84
AGING POPUL,ATIONIN THE TWENTY-FIRST CENTURY
workers alike has been to measure single dunensions of well-
being, such as mental function, social support, economic status,
physical morbidity, or capacity for self-care. However, elderly
people are subject to multiple disadvantages, and their physical,
mental, social, and economic well-being are closely interrelated-
more so than at younger ages so that combined assessment of
the various dunensions of well-be~ng is necessary.
There is a general consensus that five basic dimensions should
be included in any overall assessment of elderly individuals within
a population, namely activities of daily living, mental health,
physical health, and social and economic functioning. While it
necessary and anport ant to have information on specific areas,
functioning in one area has an impact on functioning in others.
Assessment not only should be multidimensional, but also should
be in terms of functional status.
Fillenbaum focuses on three multidimensional functional as-
sessments: the comprehensive assessment and referral evaluation
(CARE), the Philadelphia Geriatric Center multilevel assessment in-
strument (MAI), and the Older American Resources and Services
multidimensional functional assessment questionnaire- selected be-
cause they meet standards of validity and reliability. In addition,
Fillenbaum also describes the Rand Health Insurance Study (RAND
HIS) questionnaire. While it was designed for use at ages below
61, the original questionnaire was actually used in the Rand study
with persons up to age 85. With minor alterations this questionnaire
could be made fully relevant to an older population.
Fillenbaum also notes the existence of the International CIassifi-
cation of Impairments, Disabilities, and Handicaps (ICIDH), which
can be used in the classification of handicaps on a Appoint scale,
with O indicating the absence of a handicap. The classification was
published by WHO in 1980, but it has not been used in the United
States. It should be reviewed for possible use of those parts of the
classification that could be adapted to descriptions of the well elderly.
The U.S. Social Security Administration's Longitudinal Retire-
ment History Survey (SSA [RHS) is cited as an example of the use
of a multidimensional functional questionnaire over a Tong period 6
years. To illustrate the utility of such survey results, Fillenbaum uses
data from the SSA [RHS to develop a transition matrix showing the
estimated transition probabilities from each 1969 health state to each
1971 state for the [RHS sample (Fillenbaum, 1984:62~. Each of the
five dimensions is treated as a bivariate (impaired or not impaired)
yielding a matrix with 32 rows and 32 columns.
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HEALTH STATUS AND QUALITY OF LIFE
85
There is a need to reexamine existing tests and questionnaires
for use in surveys of the general population of the elderly and to
develop new instruments if needed. One criterion for deterrn~ning
the suitability of an instrument is its capacity to provide information
for measuring the complete spectrum of health from well-being to
illness and dependency and the transition rates from one state to
another over time. The second criterion for selection should be the
feasibility of applying the questionnaire in an interview survey. The
third criterion should be whether the instrument is sufficiently brief
for use in national information systems.
Recommendation 3.8: The pane] recommends (a) that the
National Center for Health Services Research and Health
Care Technology Assessment, the National Institute of Men-
tal Health, and the National Institute on Aging support
research to develop, enhance, and evaluate instruments for
measuring functional status (physical, mental health, cog-
nitive, and social) based on the behavior of active older
people; (b) that the National Center for Health Statistics
continue and enhance its effort to determine how well these
instruments address the health status of the elderly and how
the instruments might be adapted (reduced) for application
in national information systems; and (c) that the National
Institute on Aging and the National Center for Health Statis-
tics support methodological work to improve the validity and
reliability of measures of cognitive and physical impairments
of the elderly.
The emphasis in the provision of health care to the elderly should
be on maintaining functional capability and increasing active life
expectancy. Evaluation of the elderly patient must focus on what
the patient can do, relative to what the patient should be able
or wishes to do, and on identification of recent functional deficits
that may be reversible. Although a complete and precise diagnosis is
essential, the functional impact of each diagnosis should be evaluated.
Functional measures should include not only activities of daily living
(bathing, continence, dressing, eating, mobility, and walking) and
instrumental activities of daily living (e.g., doing housework/laundry,
preparing meals, shopping, getting around outside, going places not
within walking distance, managing money, taking medicines, using
the telephone) but also more subtle ejects of disease on cognitive
functions. Specific diagnoses often have little relation to functional
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86
AGING POPULATION IN THE TWENTY-FIRST CENTURY
status and the length of the diagnosis list provides little insight
into the specific needs and capabilities of a particular patient. Too
often a long diagnosis list biases physicians to think that the patient
is multiply impaired and therefore frail, although this may not be
the case at all. Diagnoses themselves are often a weak criterion for
assessing the health care needs of the elderly (Besdine, 1983~.
QUALITY OF LIFE
The General Concept
Several of the topics discussed earlier in this chapter are related
to the quality of life, which for older persons includes the extension
of longevity, the compression of morbidity, health and functional
status, and psychosocial factors as modifiers of disease. This sec-
tion discusses some of the components of quality of life, including
measures of productive activity of the elderly, and shows their rela-
tionship to those topics.
Age is not a strong predictor of subjective well-being. By and
large, older people are no less satisfied with their lives than those who
are young. Indeed, when one looks at satisfaction with the various life
domains income and standard of living, work, family and marriage,
friendships, housing and community, leisure, and health itself only
satisfaction with health declines with age. In other words, people
tend to come to terms with their lives, and most people do not
experience the terms as unduly harsh (Herzog et al., 19823.
For persons of all ages, including the elderly, the quality of life
experienced by an individual is related to his or her level of satis-
faction with life, sense of well-being, and feeling of self-worth and
self-esteem (Campbell et al., 1976; Andrews and Withey, 19763. In
contrast to objective social indicators for the population or particular
subgroups, which focus on socially significant observable events or
characteristics (such as marital status and employment), quality-of-
life measures are concerned with the subjective, psychological expe-
riences that surround or accompany these events or characteristics,
as perceived and reported by the individual (such as the level of
pride and satisfaction derived from employment). Correlations be-
tween objective social indicators and perceived quality of life for an
individual tend to be weak (Vinokur et al., 1983:32~.
Level of satisfaction has been measured globally, referring to
overall satisfaction with life; with respect to domains of life ex-
perience, such as health and mental health, marriage, family life,
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HEALTH STATUS AND QUALITY OF LIFE
87
friendships, housing, job or work, nonwork and leisure activities, and
financial situation (personal assets, financial security, earnings); and
on such dimensions as personal safety and the security of one's pos-
sessions (the latter for institutionalized persons in particular) (see,
e.g., Campbell et al., 1976; Gastil, 1978; George and Bearon, 1980;
Morgan and Smith, 19693. This view of quality of life presupposes
that an individual has aspirations and expectations that serve as the
criterion or standard against which his or her current situation is per-
ceived and assessed. The level of congruence between expectations
and perceived or actual circumstances is viewed as generating a sub-
jective evaluation of satisfaction or dissatisfaction, which is for that
individual a measure or indicator of quality of life, either glob ally or
for the particular domain in question (Franklin et al., 1984~.
Personal well-being, also a contributor to one's perceived quality
of life, is a broader concept than satisfaction with life or its domains.
According to its proponents (including Bharadwaj and Wilkening,
1977, 1980), this notion involves self-development, the realization of
one's own potential as an individual and as a social being (deriving
from MasIow, 1954), and the capacity to adapt to change and is
equivalent to a sense of personal efficacy (Vinokur et al., 1983:34~.
Feelings of self-worth and self-esteem are also related to a per-
son's assessment of the quality of his or her life (see George and
Bearon, 1980~. The belief that one's achievements and activities are
valued and needed by others and the perception that one is capa-
ble of interacting and negotiating successfully with the environment
enhance feelings of self-worth and self-esteem.
Some Dimensions of Quality of Life
Health Status
While health status is only one among many dimensions that
affect a person's assessment of the quality of his or her life, it is a
very important one. George and Bearon (1980), for example, regard
general health (and functional) status as one of four dimensions that
define quality of life for older persons, along with socioeconorn~c sta-
tus, general life satisfaction, and self-esteem and related measures.
As defined here, health status consists of physical, psychological, and
social components. The focus of survey questionnaires is typically on
physical symptoms and the functioning of organs and systems, the
ability to perform life roles, and the ability to move about. Measures
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AGING POPULATION IN THE TWENTY-FIRST aENTURY
of psychological health focus on psychological symptoms and disor-
ders. Social health is most often defined in terms of an individual's
ability to function as a member of the community, including the world
of work, and involves the nature of family relationships, friendships,
and community participation (Vinokur et al., 1983~. Yet here, as for
the other domains of life, subjective estimates of one's physical health
and well-being do not necessarily correlate with objective measures
based on laboratory findings and physical examinations (Vinokur et
al., 1983~. That is, the relationship between the presence of actual
disease and disability and perceived well-being is neither obvious
nor uniform across medical conditions. Similarly, neither increased
life expectancy nor the use of medical interventions that objectively
improve medical conditions invariably results in the perception that
one's quality of life has been improved (Vinokur et al., 1983~.
Satisfaction with Life
The elderly tend to be as globally satisfied with their lives, on
the whole, as younger persons, though their level of satisfaction
with their health status tends to decline as they advance in years.
They also tend to report their health as good or excellent and to
see themselves as functioning well. Lengthening of the life span or
longevity per se will not result in enhanced satisfaction with life
for the elderly unless personal vigor and the ability to function in-
dependently (without institutionaTization) are maintained. As noted
above, it is not known yet whether increased life expectancy will
be accompanied by an overall increase in active life expectancy for
the elderly, or rather by a prolongation of the period of dependency
and functional impairment, which does tend to increase with age.
In this connection, it is worth reiterating that aging does not in-
evitably result in decline of health status or function: older persons
are very heterogeneous with respect to health and functional status,
and improvement in both successful aging can and does occur.
Functional Status
Functional status including the ability to perform sel£care ac-
tivities and to carry out activities of daily living such as cooking,
shopping, and cleaning is more critical to quality of life than mor-
bidity or diagnosis per se. Physical, cognitive, mental health, and
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lIEALTH STATUS AND QUALITY OF LIFE
89
social functioning, individually and together, as they tend to rein-
force each other, contribute to a sense of well-being and satisfaction
with life.
Availability of Social Support System
The availability of a social support system, including actual and
potential informal supports such as family and friends, is crucial to
the quality of life for the elderly, whether residing in the community
or in an institution. Not only are positive, close, and stable family
relationships correlated with satisfaction with life (see, for example,
Najman and Levine, 1981), but also the availability of social supports
can prevent or delay institutionalization of hail elderly people.
Productive Activity
Increasing longevity should be accompanied not only by the
maintenance or enhancement of physical, mental health, emotional,
and social function, but also by productive activity that is recognized
by oneself and others as socially useful.
The development of statistics on the full range of productive
activities, especially among older men and women, is important
for both scientific reasons and national policy. Both require the
broadening of national statistical series so that they represent more
accurately the major activity patterns of men and women throughout
the life course. The lengthening of life, if it is to be meaningful to
individuals and enriching rather than burdensome to the society as a
whole, must be made as productive as possible. Measurement of the
extent to which this goal is achieved, requires accurate statistics on
the current productivity of older people and statistical information
on the factors that determine that productivity.
National data of this kind are not now available. Instead, all
paid employment is assumed to be productive and all unpaid con-
tributions to society (except for work on a family farm or business)
are ignored. These omissions are especially problematic for policy
purposes because they are age-biased. They not only underestimate
productive activity in the nation as a whole; they differentially un-
derestimate the productive contributions of different age and gender
groups.
The underestimation is greatest for those past the usual age of
retirement. When people leave paid employment, they drop from
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AGING POPULATION IN THE TWENTY-FIRST CENTURY
the conventional statistics of productive behavior for example, the
Current Population Survey no longer counts them as "in the labor
force" and consequently they are also omitted from statistics derived
from the CPS, for example, the gross national product (GNP). Peo-
ple, including the elderly, who are homemakers, who care for ill or
disabled family members, who do volunteer work in schools or hos-
pitals are classified as nonworkers as recipients and consumers who
do not produce. Policy debates over compulsory retirement, pension
entitlements, Social Security funding, and the like are therefore con-
ducted with only a partial base of knowledge, since they do not take
cognizance of the important productive work of the elderly.
The development of more comprehensive measures of productive
behavior must begin with a conceptual task: the definition of activ-
ities that are to be defined as productive. We propose a definition
that is primarily economic: an activity is productive if it generates
valued goods or services, and the key measure of its productivity is
the market value (actual or attributed) of those goods and services
minus the nonIabor costs involved in their production.
Several properties of productive behavior follow from this defi-
nition:
(1) With the exception of paid employment, for which the mar-
ket value is established by the payment, no other activity is
currently counted as productive; market value must be esti-
mated or attributed for these activities under the proposed
definition.
(2) Paid employment includes work done in both the regu-
lar and irregular (reported and unreported) economies. It
thus includes untaxed and typically unreported payment
received for work, as well as pay or profit from regular
employment.
(3) Unpaid activities that generate goods or services, and for
which market values can be determined, are likely to in-
clude housework, child care, care of ill or disabled family
members or friends, and some forms of volunteer work in
organizations. For example, the activities of a volunteer
who types letters or does bookkeeping for a civic organi-
zation fall within our definition; mere attendance at the
meetings of the organization would not.
The proposed definition permits the inclusion of activities
in which the producer is also the consumer of the product,
(4)
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HEALTH STATUS AND QUALITY OF LIFE
91
provided that such activities generate goods or services for
which a clear market value can be attributed.
As an example of the implications of this approach, consider
the painting of a house, an activity that might be undertaken by a
professional painter for wages on a regular job or as a contract for
profit. The same activity, however, might be undertaken for pay by
a person working outside a regular job. It might also be done by a
relative or friend without pay of any kind and, finally, it might be
done by the homeowner himself or herself.
The definitions and procedures of current government statistics
would include the first of these house painting done as part of a
regular job for pay or profit in its measures of employment, and
ult~rnately, its contribution to GNP. The second case house paint-
ing done as part of the irregular economy might or might not be
included. The third variation, in which the work is done as a favor to
a relative or friend, would not be included. And the fourth case, in
which the same work is done by a person for himself or herself, would
certainly not be included. Yet in all these cases, the work done is
identical. Ultimately, such work should be included in our national
statistics in such a way that it would be possible to distinguish be-
tween paid and unpaid work, and between work done for others and
that done for oneself.
Recommendation 3.9: The pane! recommends that the De-
partment of Labor, in conjunction with the Bureau of the
Census and the Department of Health and Human Services,
develop a concept of productive activity that includes both
paid and unpaid work and that can be measured and re-
ported in surveys such as the Current Population Survey,
the National Health Interview Survey, and the Survey of In-
come and Program Participation, as well as in the decennial
census.
Implementation of this recommendation would recognize the fact
that longer life means, for many elderly people, increased productive
years that have the potential to contribute to an individual's sense
of self-esteem and self-worth and thereby enhance his or her quality
of life. Once the concept of productive activity that includes both
paid and unpaid work has been developed and made operational for
purposes of collecting data via surveys, the quality of the productive
life of the elderly should be monitored.
In the absence of such statistics, no authoritative measures of
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AGING POPULATION IN THE TWENTY-FIRST CENTURY
these categories of unpaid work are available, but estimates have been
made (Goldschmidt-Clermont, 1982; Peskin, 1983~. They differ, but
all of them indicate that the goods and services generated by unpaid]
work are substantial relative to conventionally estimated monetary
GNP. No estunates of unpaid work set its total value as less than 20
percent of GNP, and some estimates range as high as 44 percent of
GNP.
Some development of measures has been done on all of the broad
activity categories with which we are concerned: paid employment,
unpaid voluntary work in organizational and informal settings, and
work that produces goods for one's own consumption. All of these
available measures involve self-report to some extent. For example,
unpaid work to operate a family farm or business is measured by
the Bureau of the Census in comparable terms number of hours
worked, occupation, and industry to those for paid employment.
Other forms of unpaid work, either in organizational settings or on
less formal bases, have been measured less frequently, less success-
fully, and less completely. The Current Population Survey provides
estimates of the number of people who are engaged in housework
and are not working for pay or profit. Mutual assistance of various
kinds has been measured mainly in terms of frequency of contact and
self-rated importance of the relations involved. The CPS incorpo-
rates no est~rnates of the monetary value of such work, but reviews
of alternative methods for making such estimates are available (see,
e.g., Goldschrn~dt-Clermont, 1982; Peskin, 1983~.
Measures of self-care have been developed, with scales of physi-
cal self-maintenance and daily living (Lawson, 1977; Kane and Kane,
1981~. The fuB range of activities in which the individual consumes
the product of his or her own work, however, has not been systemat-
ically measured.
Given the state of measurement development and the goal of
assessing the fuB range of productive activities throughout the life
course, the pane! proposes five sets of measures: (1) categories of
productive activity engaged in, (2) amount of input (hours devoted)
to such activities, (2) monetary value of the product or service result-
ing from each of these activity categories on an individual basis, (4)
self-evaluation of the productivity of the activity, and (5) outcomes
for the individual engaging in the activity and for others. These
suggestions are based on a set of propositions for which substan-
tial evidence is already available: that the reality and experience
of producing something of value or of providing a service and the
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HEALTH STATUS AND QUALITY OF LIFE
93
of producing something of value or of providing a service and the
recognition and acknowledgment of that fact by oneself and others
are conducive to improving quality of life.
Quality of Life for the ~titutional~zed Elderly
For older persons who reside in institutions such as nursing
homes rather than in the community, the factors that contribute
to satisfaction with life, a sense of well-being, and feelings of self-
worth are somewhat different from those discussed above. Already
[united in their health status and ability to function independently
and autonomously in the community two contributors to a high
quality of life such persons perceive their quality of life as heavily
dependent on the quality of their medical and nursing care. This is
especially true for the very ill and disabled (Institute of Medicine,
1986~. A recent empirical study shows that nursing home residents
also attach high importance to the qualifications, competence, and
attitudes of staff particularly nurse's aides who provide much of
the hands-on care on a day-to-day basis. Friendliness, cheerfulness,
and the treatment of residents with respect and dignity are quali-
ties highly valued in staff and are viewed as contributing heavily to
residents' quality of life (Institute of Medicine, 1986~. In addition,
such amenities as the quality of the food, the ambiance, the ability
to make personal choices and participate in planning one's own care,
and activities that assist residents in maintaining or regaining inde-
pendent function (such as rehabilitation exercises, encouragement in
ambulation or self-feeding) contribute to a high quality of life for the
institutionalized elderly (Institute of Medicine, 1986~.
Conclusion
In order to document the quality of life experienced by older
persons, both community residents and those residing in institutions,
new measures, suitable for cross-sectional and longitudinal surveys,
will have to be developed.
Recommendation 3.10: The panel recommends that na-
tional population-based surveys such as the National Health
Interview Survey and the National Nursing Home Survey
(which includes a population component) include measures
of factors that influence quality of life both positively and
negatively as people progress to advanced ages.
Representative terms from entire chapter:
functional status
