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Predictors of Life Satisfaction in Frail Elderly

Soleman H. Abu-Bader, PhD Anissa Rogers, PhD Amanda S. Barusch, PhD

ABSTRACT. This study examined the relationship between life satisfaction and physical status, emotional health, social support and locus of control in the frail elderly. A random sample of 99 low-income, frail elderly living in the community was interviewed. Almost 40% of participants reported high levels of life satisfaction. Multiple regression analysis identified four significant predictors of life satisfaction: Perceived physical health, social support, emotional balance, and locus of control. Physical health emerged as the most significant predictor of life satisfaction accounting for 14% of the variance. Social support, emotional balance and locus of control each accounted for an additional 6% of the variance in life satisfaction. All four predictors explained 32% (R = .57) of the total variance in life satisfaction. Implications for practice and recommendations are discussed. [Article copies available for a fee from The Haworth Document Delivery Service: 1-800-HAWORTH. E-mail address: <getinfo@haworthpressinc.com> Website: <http://www.HaworthPress.com> 2002 by The Haworth Press, Inc. All rights reserved.] Soleman H. Abu-Bader is Assistant Professor, School of Social Work, Howard University. Anissa Rogers is Assistant Professor, Department of Social and Behavioral Sciences, University of Portland. Amanda Barusch is Professor, Graduate School of Social Work, University of Utah. Address correspondence to: Soleman H. Abu-Bader, PhD, Howard University, 601 Howard Place, NW, Washington, DC 20059 (E-mail: sabu-bader@howard.edu). This study was funded by the Goodwill Family Foundation. Paper presented at the 4th Annual Conference of the Society for Social Work & Research, Charleston, South Carolina, January 29-31, 2000. Journal of Gerontological Social Work, Vol. 38(3) 2002 http://www.haworthpressinc.com/store/product.asp?sku=J083 2002 by The Haworth Press, Inc. All rights reserved.

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KEYWORDS. Frail, elderly, life satisfaction, physical health, social support, cognitive status, emotional balance, locus of control, life events, activities of daily livings

The life satisfaction of the elderly has been widely researched and discussed. The construct is particularly important for professionals, such as social workers, whose work aims to enhance the quality of life of the elderly. Much research in this area has analyzed how life satisfaction is influenced by factors such as social support, financial status, physical health, and locus of control. Most of this work has been conducted with healthy, community-dwelling elders. No studies to date have considered the life satisfaction of elders who have significant physical limitations (possibly because of a tendency to assume that physical problems will result in low life satisfaction). The purpose of the current study is to expand on prior studies by analyzing factors that may influence life satisfaction among frail elders. FACTORS INFLUENCING LIFE SATISFACTION AMONG THE ELDERLY Factors that influence life satisfaction include environmental characteristics, such as the availability of social support, and personal traits, such as self-esteem, physical health, financial resources, a sense of connectedness, and locus of control. Social Support and Life Satisfaction Several studies have examined the relationship between social support and life satisfaction among the elderly. Most of this literature has indicated a positive relationship between social support and life satisfaction. One study conducted by Aquino, Russell, Cutrona, and Altmaier (1996), found that social support was significantly related to life satisfaction. Aquino et al. surveyed 301 community-dwelling elders aged 65 years old and over to determine how demographic variables such as financial status, educational level, and work patterns affect life satisfaction. Results from face-to-face interviews indicated that elders who were working or volunteering showed higher life satisfaction than those who were not working or volunteering. Further, these authors found that participants who engaged in volunteer work had more social supports than those who

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were not engaged in volunteer work, which in turn led to higher levels of life satisfaction. The findings also indicated that participants who reported low education and socioeconomic levels and who had poor physical health indicated that they had few social supports and low life satisfaction. Consequently, participants who were not functioning well enough to work or volunteer had fewer opportunities to build social networks, which afforded fewer opportunities to engage in satisfying relationships outside of the workplace than participants who were working or volunteering. Though many of the measures used in the aforementioned study were standardized, particularly those measuring social support and life satisfaction, it is unclear whether these instruments are appropriate for use with older adults. In another study conducted by Newsome and Schulz (1996), 5,201 people aged 65+ were randomly selected from Medicare lists. Participants were surveyed to gather information regarding their social networks, level of functioning, perceived social supports, and life satisfaction. Results indicated that participants who reported decreased physical functioning also perceived their social supports as poor. Further, participants who perceived their social supports as poor reported low life satisfaction. Thus, participants who reported physical difficulties also perceived their social supports to be poor, which may have affected their level of life satisfaction. At this point the theoretical connection between physical functioning and social support remains unclear. While some argue that social support enhances physical health or buffers an individual from the deleterious effects of stress, these connections have not been empirically demonstrated. Personal Traits Other studies have indicated that factors such as self-esteem, perceived physical health, and locus of control are associated with life satisfaction (Girzadas, Counte, Glandon, & Tancredi, 1993; Rogers, 1999). Still other literature posits that financial security and a sense of closeness and connectedness with others predict life satisfaction (Fisher, 1995; Girzadas et al., 1993; Gray, Ventis, & Hayslip, 1992; Kahana et al., 1995; Levitt, Antonucci, Clark, Rotton, & Finley, 1986; McGhee, 1984; Revicki & Mitchell, 1986; Wing-Leung Lai & McDonald, 1995). Indeed, Kahana et al. (1995) found that short-term problems such as those caused by financial difficulties and changes in relationships through retirement or death may have a significant impact on life satisfaction.

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Locus of control has been another widely studied construct in relation to life satisfaction among the elderly. Most research has focused on the relationship between internal, external, and chance locus of control and life satisfaction, and conclusions as to the nature of this relationship have been mixed. In an exploratory study conducted by Girzadas et al. (1993), 258 community-dwelling individuals aged 55+ were selected from a larger study that examined the relationship between health status, locus of control, and life satisfaction. The larger study recruited participants from the rolls of Health Maintenance Organizations and private physicians. Results from face-to-face interviews with participants indicated that functional health status was positively associated with life satisfaction. Further, participants who scored high on chance locus of control also scored low on life satisfaction. Specifically, participants who reported poor physical health and who demonstrated a tendency toward believing their health outcomes were based on chance also showed relatively low life satisfaction. Results from other studies suggest that individuals with a tendency toward internal locus of control, particularly with regard to physical health, show higher levels of life satisfaction than those who show a tendency toward external or chance locus of control (e.g., Haber, 1994; Searle, M. S., Mahon, M. J., & Iso-Ahola, S. E., 1995; Wing-Leung Lai & McDonald, 1995). It follows that older adults who are not internally focused may show a tendency toward low life satisfaction. For instance, Park and Vanderberg (1994) found from a sample of 154 individuals aged 58+ that those who demonstrated low levels of personal autonomy and high levels of dependency tended to be more negatively affected by poor health and showed a need for social support in the form of a confidant than more autonomous and independent individuals. Moreover, Vallerand, OConnor, and Blais (1989) found that older adults living in nursing homes that did not allow for personal autonomy or self-determination showed lower life satisfaction than older adults living in nursing homes that allowed for more personal independence or those living independently in the community. Conversely, some studies have indicated that older adults who demonstrate a tendency towards external locus of control have higher life satisfaction than those with an internal or chance locus of control (e.g., Haber, 1994; Rogers, 1999). It may be that older individuals who are externally focused and who have developed trust in their health care provider actually demonstrate higher levels of life satisfaction than those who rely on themselves or even chance for health care decisions. Specifically, the latter group may experience more guilt or feelings of hopelessness when

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faced with health problems, poor treatment, or poor decision making with regard to health care (Haber, 1994). In summary, studies of life satisfaction among elderly have identified several important constructs that may influence this measure. These constructs include the following: social support, physical health, locus of control (internal, external, and chance), financial status, and life events. Using multiple regression analysis, the current study incorporated these and other measures to develop a model that best describes factors associated with life satisfaction among frail elderly. METHODOLOGY Sample Recruiting Methods. Participants for this study were randomly selected from clients of The Alternatives Program (TAP) in Salt Lake County, Utah. TAP provides services such as adult day care and homemakers to low-income adults whose physicians certify that they are at risk of nursing home placement. Of the 182 TAP clients contacted, 102 (56%) were interviewed, of whom 99 were 60 years old and over and thus included in the final analysis. Of the 99 subjects, 87 (88%) were women. Program staff provided access to demographic information on non-participants, and independent t-tests and chi-square analyses were conducted to identify differences in age, race, gender, income, and living status (whether or not the respondent lived alone) between participants and non-participants. These analyses yielded significant differences in age (t = 2.42, p = .017). Older TAP clients refused to participate in the study more frequently. Analyses revealed no significant differences on other variables. The most common reason for non-participation, given by 43% of those who declined, related to poor health and cognitive difficulties. Others (26%) indicated they just did not want to be interviewed, while the remainder cited other reasons. Participant Characteristics. Participants in this study were predominantly white (94%). Their mean age was 78 years (SD = 8.5) with a range from 60 to 101 years. The median monthly income was $575 with a range from $257 to $1,584 per month. The vast majority (81%) were either widowed (53%) or divorced (28%). The majority (70%) lived alone. The modal level of education was high school (34%). Respondents were frail, needing assistance with an average of 2.6 Activities of Daily Living (ADLs) and 5.3 Instrumental Activities of Daily

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Living (IADLs). Respondents reported their health to be fair (38%) to good (24%). Over one third (36%) had a diagnosis relating to the musculoskeletal system, primarily a form of arthritis. The next most common diagnostic category was neurological, with 24% of the sample experiencing an illness of this kind. This was followed by cardiovascular illness, experienced by 19% of the sample. The mean duration of illness was 14 years, with a range from 1 to 70. Half (53%) of the sample reported a steady decline associated with their illness. Others reported that their conditions were stable (16%) or had variable up and down trajectories (14%). A few respondents (10%) reported their condition had recently improved. Data Collection Interviews. Trained undergraduate and graduate MSW students conducted in-depth interviews in respondents homes. Interviews lasted one to three hours. When participants became fatigued, interviewers completed the interview in a second home visit. While most of the protocol was highly structured, interviews closed with a guided conversation designed to explore respondents understanding of the impact of physical illness on their lives and emotional well-being. For individuals with significant cognitive impairment, interviews were conducted with visual aids and additional time was allowed. Instruments. A general demographic section recorded age, gender, race, religion, education, marital status, participants occupation, spouses occupation, primary diagnosis, length of residency in home, alcohol and prescription drug use, home ownership, and living arrangement. The dependent variable, life satisfaction, was measured using the LSI-Z (Wood, Wylie, & Sheafor, 1969). The LSI-Z is a shorter form of the LSI-A (Neugarten, Havighurts, & Tobin, 1961). The LSI-Z contains 14 items that respondents rate agree, disagree, or uncertain. Possible total scores range between 1 and 14 with higher scores indicating higher life satisfaction. The LSI-Z is a self-report measure that has been normed on 100 elderly subjects with a mean life satisfaction score of 11.6 and a standard deviation of 4.4 (Sauer & Warland, 1982). The LSI-Z has a Kuder-Richardson reliability1 coefficient of .79. The Iowa Self-Assessment Inventory (Morris & Buckwalter, 1988) is 56-item scale that consists of seven subscales including economic resources, emotional balance, physical health, trusting others, mobility, cognitive status, and social support. Items are rated on a scale from 1 (usu-

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ally or always true) to 4 (usually or always false). The scores for each item are summed to comprise a score that ranges from 8 to 32. This inventory primarily has been normed on adults 65+ years old (Morris, Buckwalter, Cleary, Gilmer, & Andrews, 1992). The internal consistency reliability coefficients for the seven subscales range from .74 to .86 (Morris, Buckwalter, Cleary, Gilmer, Hatz, & Studer, 1990). Construct validity has been shown between each subscale and similar measures (Morris, Buckwalter, Cleary, Gilmer, Hatz, & Studer, 1989). The Geriatric Scale of Recent Life Events (Kiyak, Liang, & Kahana, 1976) is a 55-item scale that measures the number of life events that have occurred within the previous three years. Subjects circle all events that they have experienced, and the number of events circled is summed to comprise a total score. Item examples include: Death of a Close Friend; Minor Illness; Gain a new family member; and Grandchild married. This scale was normed on 248 individuals 60+ years old and has shown good concurrent validity (.51 to .84) (Kiyak, Liang, & Kahana, 1976). The analysis reported here was based on a subscale of negative events constructed for the study. It included 32 items. The Multidimensional Health Locus of Control Scale (MHLC) (Wallston, Wallston, & DeVellis, 1978) is an 18-item instrument that rates respondents according to internal health locus of control (IHLC), powerful others health locus of control (PHLC), and chance health locus of control (CHLC). Respondents answer questions on a 4-point, Likert-type scale (1 = strongly disagree to 4 = strongly agree). Scores on each subscale are summed, and higher scores indicate more external beliefs in locus of control. Typical questions include: No matter what I do, if I am going to get sick, I will get sick and Most things that affect my health happen to me by accident (Wallston et al., 1978). Inter-item reliability has been estimated to range from .67 to .86. Concurrent validity with similar locus of control measures has been estimated to range from .51 to .73. This scale was normed on the general population, with a median age range from 35 to 44 years. The Index of Activities of Daily Living (ADL) (Katz, Ford, Moskowitz, Jackson, & Jaffee, 1963) is a widely used measure that assesses a persons ability to carry out daily tasks such as walking, getting out of bed, climbing stairs, grooming, bathing, dressing, toileting, and feeding. Items are rated yes or no in terms of dependence or independence for each activity. This index has shown good interrater reliability, as well as strong correlations with measures of mobility and house confinement (Kane & Kane, 1981).

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Finally, perceived health in general was measured by a 5-point Likert scale item In general, would you say your health is excellent, very good, good, fair, or poor. Data Analysis Two multiple regression methods, hierarchical and stepwise methods, were conducted to determine which psychosocial measures were significantly associated with life satisfaction among respondents. Measures that have shown significant correlations (p < .05) with life satisfaction were entered in the regression equation. These variables were number of negative life events, emotional balance, physical health, cognitive status, social support, powerful others locus of control, and perceived health in general. The dependent variable was life satisfaction, as measured by the LSI-Z. Prior to these analyses, frequencies and histograms were generated for all variables to assess distributions and outlying cases. All variables were normally distributed and had no outliers. For the regression analysis, diagnostics were performed to ensure multivariate assumptions were met. Bivariate correlation matrices, variance inflation factor (VIF) values, and tolerance criteria indicated no multicollinearity among the independent variables. FINDINGS Descriptive Findings Life Satisfaction. To describe the life satisfaction of participants in this study, we computed descriptive statistics using the dependent variable, life satisfaction. The mean score on the Life Satisfaction Index was 9.6 (SD = 2.5), slightly below the cutoff score (11.6) for a normal population of elderly as reported by Sauer and Warland (1982). Scores on the life satisfaction ranged from 3 to 14, with 39% of participants reporting a score of 11 or higher (61% below the cutoff score). Cognitive Status. Cognitive status was gauged using the Mini Mental State Exam, as well as the cognitive status sub-scale from the Iowa Self-Assessment Inventory. The mean score on the Mini Mental State Examination was 25.8, with a range from 13 to 30. Folstein, Folstein, and McHugh (1975), suggest using a criterion of 21 or less to gauge cognitive impairment. Using this cut-off, only 14% of respondents showed signifi-

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cant cognitive impairment. Further evidence of cognitive capacity was provided by the cognitive status subscale from the Iowa Self-Assessment Inventory. The mean score on this measure was 21.7, with a range from 8-32. Locus of Control. Participants in this study showed a clear tendency toward external causal attributions. Their mean score on the Internal Locus of Control sub-scale was 5.6, with a range from 2 to 8. The mean score on external (powerful others) sub-scale was 14.7, with a range from 6 to 24. Respondents mean on the chance sub-scale was 12.4, with a range from 6 to 19. Mean scores obtained when this instrument was normed were 25.1 on the Internal Locus of Control sub-scale; 19.9 on the Powerful Others sub-scale, and 15.6 on the chance sub-scale (Wallston et al., 1978). Table 1 displays results for these descriptive analyses. Life Events. The average number of negative life events participants experienced in the year prior to this study was 7.5, with a range from 2 to 17. The most common event reported was difficulty walking, experienced by 85% of the sample. This was followed by minor illness (84%), reduced recreation (76%), illness of a family member (60%), hearing and vision problems (56%), and less church activity (49%). Nearly half (48%) of the sample had experienced death of a family member. Table 2 displays the negative life events included in this study. Predicting Life Satisfaction Hierarchical and stepwise multiple regression methods were conducted to estimate a model predicting life satisfaction. As was previously mentioned, variables that were significantly correlated with life satisfaction were entered in the regression equation. Table 3 presents the correlations between the dependent variable (life satisfaction) and the independent measures. The results of both hierarchical and stepwise multiple regression methods were consistent, and therefore, the results of the stepwise are reported in this study. These results are presented in Table 4. These results show that life satisfaction is a function of physical health (beta = .26, p < .0001), social support (beta = .19, p = .007), emotional balance (beta = .34, p = .039), and powerful others locus of control (beta = .28, p = .003). The results show that physical health has the strongest contribution to the variance of life satisfaction. It contributes 14% of the variance in life satisfaction, while each one of the other variables contributes 6% of the variance. All four variables combined contribute 32% (R = .57) of the total variance of life satisfaction.

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JOURNAL OF GERONTOLOGICAL SOCIAL WORK TABLE 1. Respondents Cognitive and Emotional Status (N = 99)

Variable

Mean

Median

SD

Range

Life Satisfaction Physical Health Economic Resources Emotional Balance Trusting Others Mobility Cognitive Status Social Support Activities of Daily Living Powerful Others Locus of Control Internal Health Locus of Control Chance Health Locus of Control

9.6 15.4 22.5 23.2 28.1 16.0 21.7 27.3 2.6 14.7 5.6 12.4

10.0 14.0 22.0 24.0 29.0 16.0 22.0 29.0 3.0 15.0 6.0 13.0

2.5 4.7 6.0 6.2 4.3 5.1 5.6 5.4 1.8 3.4 1.4 3.3

3-14 7-26 5-32 10-32 13-32 5-30 8-32 10-32 0-8 6-24 2-8 6-19

DISCUSSION This sample of frail elders reported levels of life satisfaction that were somewhat lower than those observed in studies of more healthy elders. In this study, the mean score of life satisfaction (9.6) was slightly below scores reported in studies of healthy seniors. In these studies, mean life satisfaction scores have ranged from a low of 11.6 to a high of 15.39 (Kahana et al., 1995; Wood, Wylie, & Sheafor, 1969; Rao & Rao, 1981; Gray, Ventis, & Hayslip, 1992; Adams, 1969). This difference is small, and a significant proportion of respondents in this study reported levels of satisfaction that were well within the range of those reported by more healthy elders. Indeed, these results underscore what practitioners in the field already know. Namely, that not all frail elders experience low life satisfaction. In this sample, nearly half reported high scores on this measure. It is tempting to attribute the samples lower mean life satisfaction to health and functional limitations. But results of the multivariate analysis do not support this interpretation. The subjective measure, perceived physical health was an important predictor of life satisfaction, whereas more objective health measures were not. In bivariate analyses reported in Table 3, more objective measures of functional ability (IADL and ADL)

Abu-Bader, Rogers, and Barusch TABLE 2. Negative Life Events (N = 99)

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Event Difficulty Walking Minor Illness Reduced Recreation Family Member Ill Hearing/Vision Problems Less Church Activity Death of Friend Death of Family Member Major Illness Financial Difficulty Stopped Driving Friends Turned Away Victim of Crime Loss of Possessions Moved into Home for Aged Trouble with Children Trouble with Neighbor Age Discrimination Took Large Loan Sexual Difficulty Argued with Spouse Divorce Death of Spouse Legal Violation Separation Unfaithful Spouse

Number Reporting 84 83 75 59 55 48 47 45 45 36 26 15 15 14 13 12 11 9 8 8 6 3 3 3 2 1

% of Sample 85 84 76 60 56 49 48 46 46 36 26 15 15 14 13 12 11 9 8 8 6 3 3 3 2 1

did not show a significant association with life satisfaction. In contrast, personal health appraisal was significant in the bivariate analysis (r = .38). Further, the measure was the most important predictor in our model predicting life satisfaction. This is consistent with findings of other studies (e.g., George, 1993; Henderson et al., 1993) that indicate that subjective perception may be a better predictor of life satisfaction than actual functional ability. Clearly, apart from more objective measures, an individuals perception regarding his or her health is an important correlate of life

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TABLE 3. Correlations Between Life Satisfaction and the Independent Measures (N = 99)
Variable Physical Health Emotional Balance Social Support Negative Recent Life Events Cognitive Status Powerful Others Locus of Control Instrumental Activities of Daily Living (IADLs) Trusting Others Internal Health Locus of Control Activities of Daily Livings (ADLs) Chance Health Locus of Control Mobility Economic Resources r .38** .34** .31** 2.26* .20* .20* .13 .13 .12 2.07 .05 .05 .02

*p < .05 **p < .001

TABLE 4. Predicting Life Satisfaction


Variable Physical Health Social Support Emotional Balance Powerful Others Locus of Control R .38 .45 .51 .57 R2 .14 .20 .26 .32* beta .26 .19 .34 .28 SE .05 .04 .04 .07 t 2.79 2.10 3.50 3.03 p F p .000 .000 .000 .000

.006 15.69 .039 12.12 .001 10.78 .003 11.08

Adjusted R2 = .30

satisfaction. Practitioners who work with the frail elderly may find that perceived health status serves as a proxy for other measures of well-being. Thus any assessment of this population should include this parsimonious measure. Because this study is correlational, it is unclear whether results have identified factors that cause life satisfaction. Findings mirrored those of

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other studies in the important role of social support, emotional balance, and powerful others locus of control in the life satisfaction of the frail elderly. Clearly, as suggested by the results of multiple regression, frail elders who perceive their health as poor, who have limited social supports, and whose emotional status is fragile should be considered likely candidates for low life satisfaction. This study affords some practical implications for professionals committed to enhancing the quality of life of frail elders. First, it is important that assessments include a simple measure of perceived physical health. This is an efficient way to appraise, not only physical well-being, but also life satisfaction and possibly emotional status as well. Second, while it is unclear whether life satisfaction is amenable to clinical intervention, efforts to enhance the quality of life for frail elders would do well to consider the Life Satisfaction Index a possible evaluation measure as one most likely to reflect the overall success of their efforts. Finally, in illustrating the importance of diverse factors in predicting life satisfaction this study underscores the importance of holistic intervention that addresses not only personal traits and perceptions, but also social support and resources. NOTE
1. For more information about Kuder-Richardson Reliability see Crocker and Algina (1986).

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DATE MANUSCRIPT RECEIVED: 11/5/01 DATE MANUSCRIPT SENT FOR BLIND REVIEW: 11/6/01 DATE MANUSCRIPT RE-RECEIVED IN ACCEPTABLE FORM: 2/20/02