The results of this study point out institutionalized elderly have low HRQoL and the main factors that influence their quality of life are associated with their performance of daily-living activities, functional status and depression status. Once institutions could promote activities to reduce dependency, frailty and depression, the institutionalized elderly’s quality of life can be significantly improved.
Brazil has an important cultural diversity and socioeconomic inequalities, resulting in heterogeneous institutions for elderly with regards to provision of services, physical structure, financial resources and the strata of public served . In this context, it is evident that the quality of life experienced by different elders may vary within the same institution and among different places. However, this study point out that long-term care facilities may improve the way-of-life of their residents through physical and mental health promotion activities, which may impact positively their general health-related quality of life .
A substantial impact of physical, cognitive and psychological disabilities on HRQoL of institutionalized elderly has been demonstrated . According to this previous study, providing psychological, physical and occupational interventions could significantly improve HRQoL of nursing home residents. The results of our study corroborate with those previously reported, since it was also detected a relationship between physical (performance on daily-living activities and frailty status) and psychological (depression status) status on HRQoL of institutionalized elderly.
Some studies emphasized that institutionalization process does not necessarily result in a worse quality of life. Although institutionalized elderly have low HRQoL, this condition is possibly associated with factors that led them to institutionalization, such as very advanced age, low scholarship, low autonomy and low social participation [27,28]. Investigating factors associated with the perceived quality of life of institutionalized and non-institutionalized elderly is of relevance to determine the effects of institutionalization on the HRQoL . In this study, only the HRQoL of institutionalized elderly was investigated as dependent variable.
According to our data, dependency was associated with worse HRQoL of institutionalized elderly. The reduction in the body mass and loss of muscle tone are characteristics involved in aging process and these factors imply in the reduction of movements and decrease of functional performance during daily activities [30,31]. The lack of physical stimulation in institutions increases the probability of functional disorders in elderly, which affects their HRQoL . A previous study has demonstrated that lower levels of physical activity were associated with institutionalization .
In addition to a pre-existent condition, long-term care institutions frequently limit elderly’s active lifestyle due to the lack of sufficient personnel and infrastructure . In our study, none of the institutions investigated presented a regular program of physical activities for the elderly and this fact may be related to the reduced number of employees. In general, institutions have small number of professionals that are required to perform many functions, including the practice of regular physical activities among elderly.
Although this study did not show an impact of nutritional status on the HRQoL of institutionalized elderly, previous studies have shown that malnutrition may contribute to increased mortality and greater susceptibility to infections, which may reduce the elderly’s quality of life [35,36]. Other studies emphasize malnutrition is related to functional disability, as result of muscle strength decrease and reduction of cardiorespiratory performance [37,38].
The relationship between frailty and HRQoL may also be associated with the functional disability, with regards to physical, cognitive, social and psychological domains . The poor heath status increases the incidence of elderly’s mortality, hospitalization and institutionalization , which obviously impact the HRQoL. Poor nutritional status frequently accelerates the onset of frailty and predisposes elderly people to chronic diseases . Therefore, frail elderly must be subjected to nutritional supplementation and physical activities in order to improve functional performance, nutritional status and the overall quality of life .
The overall prevalence of frailty in the community-dwelling population of western countries has been reported to range from 6% to 40% [42,43,44,45]. We detected that 46.1% of participants were considered frail, and this impacted significantly the HRQoL of institutionalized elderly. Although there is evidence of the large benefits of exercising in improving functional and mental domains of elderly’s quality of life, no recommendations have been made to date concerning the structure of exercise programs directed to frail institutionalized elderly [46,47]. None physical exercise programs were observed within the institutions visited in our study. Valid interventions for community-dwelling older adults are not necessarily valid for nursing home populations, since institutionalized elderly have higher rates of disability, multimorbidity, and geriatric syndromes .
Depression is the most prevalent functional mental disorder in elderly people. It is projected that depressive illness will be the second leading cause of disability worldwide in 2020 . The degree of unhappiness and suffering in people with depression is not easily measured, although one possible way is to assess the impact of depression on their quality of life. Even minor levels of depression have been related to a significant quality of life decrease among elderly . The results of this survey showed that depression status was associated with lower HRQoL among institutionalized elderly. Developing programs for psychological monitoring and depression prevention are therefore necessary. This would aid reducing the negative effects of depression on HRQoL. Although GDS is not a valid instrument for diagnosing depression, it has an excellent applicability in long-terms care institutions. GDS can contribute to monitoring the prevalence of symptoms related to depression .
The relationship between depression and poor quality of life perception among elderly has been demonstrated previously . The loss of independence and privacy within long-term care institutions, apart of frequently being distant from own family, can aggravate the depression status among institutionalized elderly . Psychological illness is usually associated with lower life enjoyment and demotivation, which implies in lower functional capacity and lower quality of life .
The results of this study did not find statistical associations between geriatric self-perceived oral health (GOHAI) and HRQoL. The oral health of institutionalized elderly was previously characterized by high frequency of tooth loss, lack of regular preventive care and lack of dental treatment [52,53]. This illustrates that oral health is undervalued among institutionalized elderly. Therefore, the self-perceived oral health does not seem to impact the HRQoL of institutionalized elderly. Nevertheless, improvement of elderly’s oral health would possibly impact the masticatory function, nutritional status and self-esteem.
It is important to consider this is a cross-sectional study and statistically significant associations may not always represent a cause-effect relationship. Although the sample sized can be considered limited, this was set by a sample size calculation and it represents the whole number of institutionalized elderly that could answer the validated questionnaires. The results of this study can be set as representative of institutions from the capital cities of Brazil Northeast, as well as other countries with similar economical status or long term care institutions structure. Results of this study could aid institutions to promote physical and psychological interventions to prevent dependence, frailty and depression among institutionalized individuals.