Date of Award

8-17-2009

Document Type

Open Access Thesis

Degree Name

Medical Doctor (MD)

First Advisor

Terri Fried

Second Advisor

Paul Kirwin

Third Advisor

Lisa Walke

Abstract

Longitudinal Evaluation of Quality of Life in Older Persons with Advanced Illness Rachel Solomon, Paul Kirwin, and Terri Fried. Section of Geriatrics, Departments of Internal Medicine and Psychiatry, Yale University School of Medicine, New Haven, CT; VA Connecticut Healthcare System. Background: Efforts to understand and evaluate quality of life (QoL) among persons with chronic disease have resulted in the development of indices that measure QoL according to the severity of disease, symptoms, and functional impairments. By definition, inclusion of these domains presumes that QoL declines as illness progresses. However, this assumption may not reflect the subjective experience of QoL in older persons with advanced illness. There has been little empiric longitudinal study of QoL in this population. Methods: At interviews performed at least every four months for up to two years (more frequently for individuals with significant changes in their health status), 185 community-dwelling individuals ≥60 years of age with advanced cancer, heart failure, or chronic obstructive pulmonary disease were asked "How would you rate your overall quality of life?" Response choices included: worst possible, poor, fair, good, and best possible. Results: We identified four different QoL trajectories which we defined as: improving (QoL rating in at least one interview was higher than that at the previous interview and either improved or remained the same at each of the subsequent interviews); worsening (QoL rating in at least one interview was lower than that at the previous interview and either declined further or remained the same at each of the subsequent interviews); no change (QoL ratings at each time point were the same); and variable (there were two or more changes in the direction of the trajectory over time; e.g. QoL improved then worsened or vice versa). Nearly one-half (49%), of participants reported variable QoL trajectories. Among participants who died during the study, 46% reported good or best possible quality of life at the last interview and 21% reported improvement in QoL from the second-to-last to final interview. Functional status, symptoms, self-rated health, social support, and religious identity were associated with QoL in bivariate analysis; in multivariable analysis, greater activities of daily living disability and depressed mood were significantly associated with a lower QoL, while higher self-rated health and feeling closer to one's religious community were significantly correlated with higher QoL ratings. Conclusions: Declining QoL is not an inevitable consequence of advancing illness, but rather appears to be highly variable over time. Although QoL may decline with objective measures of worsening illness, a sense of closeness to a religious community and higher subjective ratings of health appear to preserve QoL despite worsening illness.

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This is an Open Access Thesis.

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