Our objective was to determine the correlates of HRQoL in the general older population in Guadeloupe. We found that complaints of pain were associated with poorer HRQoL. Several studies have also found that pain16,17 was associated with an altered HRQoL. In 2003, Jakobsson18,19 found this association in the Swedish population over 70 - including after stratification on age. Lacey 17 et al. found similar results in Ireland in 2014 and established a relationship between pain and physical and mental components of HRQoL, using the SF-12 questionnaire, a validated HRQoL assessment. It is difficult to report on the pain experience itself. There are several components to pain, including the affective-emotional one. Chronic pain is strongly associated with incident anxiety and depression15,16, which contributes to the deterioration of quality of life.
The diagnosis of pain in older people is challenging. People with cognitive disorders may underestimate their pain in self-rated scales due to difficulties in perception, expression, analytical faculties, or global understanding.20,21 Hunt et al. showed that proxies tend to report more pain than participants. They found that up to 30% of older people suffering from various types of pain took no pain medication.22
As untreated pain is the cause of functional limitations and impacts quality of life, pain management is essential. Assessing physical quality of life requires self- or proxy-assessment, which accounts for context and comorbidities, to select the appropriate treatment. Although this association is often found in the literature, alleviating pain and complaints of pain does not necessarily improve quality of life.
In our study, impairment of IADL was associated with lower quality of life. This result is even more relevant as studies show an association between pain and IADL impairment. Covinsky et al. in 2009 and Shega et al. in 201023,24 showed that significant pain correlates with functional limitations and their early appearance, especially with high-prevalence pathologies in later life, such as osteoarticular disorders. Location of the pain (for example, lower limbs) is a risk factor for dependence and lower quality of life.
We found no association between neurocognitive impairment and quality of life (correlation coefficient: 0.129; p=0.171). Although the data available in the literature generally agree with this result, it depends on the population or the assessment instruments. In a study on subjective quality of life, Baptista et al. show that people with mild cognitive impairment were more aware of their impairment than those with severe cognitive impairment. Awareness of the disorder was associated with lower reported quality of life than those unaware.25 Hill et al. also showed that the mere complaint of subjective cognitive impairment would negatively impact the quality of life of individuals compared to those without such complaints.26 On the other hand, in advanced stages of neurocognitive disorders, certain studies such as that of Selwood et al. or Missotten et al. show no association between the evolution of cognitive disorders and quality of life over time in cohort studies27,28.
Assessing subjective HRQoL is a challenge in older people suffering from cognitive impairment. Self-report methods may be inappropriate in people with severe disorders, as they involve understanding the complex concept of quality of life. Nevertheless, various validated HRQoL scales exist for patients with dementia, depending on the type of dementia, the degree of severity of the disease, and the place of living of the patient29.
In our study, in the absence of other assessments of cognition, only the threshold of 24/30 on the MMSE allowed us to classify our participants according to their level of cognitive impairment. A more thorough diagnostic approach could have allowed us to characterise them more precisely and propose complementary, more appropriate assessments.
Other studies also demonstrate the significant contribution of social support to predict quality of life30 and as a buffer to stress.31
The "quality of life gap theory" defines quality of life as the gap between someone's ideal life and the perceived reality. Individuals with poor "objective" health might thus report good quality of life when reality matches their expectations.32,33
Other factors are crucial to the quality of life of older people, for instance, social support from family or professional caregivers or participation in social activities (seniors' club, Alzheimer's network). This type of assistance reduces the daily organisational burden and the preservation of the social fabric and is a pivotal determinant of quality of life.31
Specific studies of these characteristics in the Guadeloupian population could help refine our knowledge of the determinants of health and HRQoL in this population.
Clinical impact of the study
Our results provide an opportunity to emphasise the relevance of a systematic assessment of pain during home and office visits, whether by the general practitioner or the nurses.
Since pain negatively influences quality of life, optimal management of this former is essential, especially since older people report higher scores than younger adults. Given the data in the literature and our results, analogue scales are efficient tools, easily implemented in routine care. Indeed, the evolution of the scores is easy to trace in the medical record. Nevertheless, a regular reassessment of the relevance of this tool is essential in the case of neurocognitive disorders. Nevertheless, managing pain in older adult to improve QoL is an objective to which GPs will be sensitive.
In regard to IADL dependency, the GPs interest remains rather modest in spite of many geriatricians, neurologists and others efforts for several years. Nevertheless, our result is very interesting concern the future of management strategies for dependency to IADL, because preserving QoL is fundamental for GPs.
Our analysis presents several limitations. First, the design of our study does not allow for the determination of causal relationships between pain, IADL impairment, and HRQoL. Second, self-reported health is a unidimensional proxy for HRQoL. As such, it fails to capture the multidimensionality of this latter. Nevertheless, despite a small number of participants (115), study participants were representative of the older population in terms of pathologies and other associated comorbidities.