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Psychosocial factors and health as determinants of quality of life in community-dwelling older

adults

Caroline E Bretta, Alan J. Gowa,b, Janie Corleya, Alison Pattiea, John M. Starrb,c, Ian J Dearya,b*

a
Department of Psychology, University of Edinburgh, Edinburgh, UK
b
Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, Edinburgh, UK

c
The Geriatric Medicine Unit, University of Edinburgh, Royal Victoria Hospital, Edinburgh, UK

*To whom all correspondence should be addressed

Ian J. Deary
Department of Psychology
University of Edinburgh
7 George Square
Edinburgh EH8 9JZ
Scotland, UK

Tel. +44 131 650 3452

Email [email protected]
Abstract:
Purpose It is important to understand the determinants of differences in quality of life in old age,
and to include a wide range of possible predictors. The present study investigated the determinants
of quality of life in two groups of older adults for whom there was an unusually informative set of
possible predictor variables.
Method Participants were members of the Lothian Birth Cohorts of 1921 (n = 550) or 1936 (n =
1091). Four facets of quality of life (QoL) and general QoL were measured using the WHOQOL-
BREF. Possible determinants included: personality traits, measured with the International
Personality Item Pool (IPIP) scales; childhood and old age general cognitive ability, measured with
the Moray House Test; minor psychological symptoms, measured with the Hospital Anxiety and
Depression Scale (HADS); physical health, assessed by grip strength and cardiovascular disease
history; and sociodemographic factors, assessed by interview.
Results Linear regression analyses revealed that HADS depression had the greatest influence on
quality of life. Personality traits, most notably Emotional Stability, also predicted quality of life to
varying degrees, along with factors reflecting current life circumstances. There were differences
between the two cohorts in the variables which predicted quality of life. There were different,
conceptually relevant, contributions to the different QoL facets.
Conclusions Personality traits and minor depressive symptoms have an important influence on self-
reported quality of life in old age. Quality of life may be influenced more by current than past
circumstances, and this relationship may change with age.

Keywords

Quality of life; Big Five personality traits; depression; older adults; health; sociodemographic
factors; anxiety

Abbreviations

MHT = Moray House Test

SMS = Scottish Mental Survey
LBC = Lothian Birth Cohort
HADS = Hospital Anxiety and Depression Scale
WHOQOL-BREF = World Health Organization Quality of Life Scale – Brief version
WHOQOL-100 = World Health Organization Quality of Life Scale
QoL = Quality of Life
IPIP = International Personality Item Pool
SD = Standard Deviation
CVD = Cardiovascular disease
PCA = Principal Components Analysis
IQ = Intelligence Quotient
Introduction

Quality of life is an important aspect of human existence that can be defined as “individuals’
perceptions of their position in life in the context of the culture and value systems in which they live
and in relation to their goals, expectations, standards and concerns” [1]. It is thought to be subject to
both external and internal influences and, in turn, has important implications for well-being and
future health outcomes such as mortality and recovery from illness [2, 3]. Research in the field has
suffered from a lack of consensus over the exact definition of ‘quality of life’. However, recent
work has identified some commonly-agreed elements. Cummins et al. [4] reviewed 27 definitions
of QoL and identified four common components: emotional well-being, health, intimacy issues, and
work and productivity [5]. Others have suggested that quality of life is a multidimensional concept
incorporating physical and psychological well-being, social participation and lifestyle factors, and
an individual’s expectations for their life [6, 7]. Many researchers assert that QoL and subjective
well-being, while related to social indicators such as wealth, education and physical health, are
more influenced by individual factors such as personality, values and mood [8].

Maintaining a good quality of life is especially important in older adults, who often experience poor
functional health and are more vulnerable to negative health outcomes. The nature of the
relationship between age and QoL remains ambiguous [9, 10]. Many studies report that QoL
improves with age [11], while others report no difference between young and old adults [12], even
despite increased functional decline in older adults [13]. Most research in the area has been cross-
sectional rather than longitudinal in nature and may therefore reflect cohort rather than age
differences [14]. There has been a paucity of research amongst older age groups; those investigating
older old age have suggested an accelerated decline in QoL [14], possibly due to a reduction in
cognitive resources available for compensatory strategies [15]. Baltes and colleagues applied a
lifespan approach to ageing, suggesting that well-being and QoL are maintained through the
adaptive psychological processes of selection, optimisation and compensation [16] but that
accelerating functional decline in old-old age pushes the limits of adaptive psychological capacity,
resulting in lower subjective well-being [17]. This was reflected in the distinct psychological
profiles observed in the oldest participants within their own study [18].

Understanding the factors influencing QoL in old age could have important implications for future
interventions aimed at improving QoL and health outcomes. Functional health, physical
environment and life circumstances such as social deprivation and physically demanding working
conditions may all play a part [19]. People’s current circumstances such as ill health, cognitive
status and mood may influence QoL more than historical factors such as childhood deprivation and
education [19, 20]. However, one study [6] found that QoL in older adults was predicted by
childhood mental ability and, assessed contemporaneously in old age, personality traits and freedom
from minor psychological symptoms. Other studies have argued for a significant role of depressive
state in predicting QoL in older adults, over and above life circumstances such as acquired poverty,
poor health, loss of independence, and cognitive abilities [6, 20]. Others suggest that a key role is
played by social relationships [21] and perceived social support [2]. Some have suggested that the
processes behind QoL judgements alter with age, arguing that physical impairments are gauged as
being less serious when compared with peers, and that the effects of current circumstances on QoL
grow weaker with age, especially in women [7].

There is considerable evidence for an association between personality traits and QoL and subjective
well-being [22-24]. Personality traits have relatively high stability over the lifecourse, providing a
consistent and stable indication of how an individual might perceive and respond to life’s
challenges [5, 25]. Some studies have found that self-reported quality of life is associated with
aspects of personality such as self-efficacy, optimism, goal adjustment and harm avoidance [5, 20,
24, 26]. Many personality theorists argue for the presence of five superordinate factors which are
viewed as being fundamental to the description of personality differences: Extraversion,
Neuroticism/Emotional Stability, Agreeableness, Conscientiousness, and Openness to experience
(also called Intellect/Imagination). High levels of Neuroticism and/or low levels of Extraversion are
related to lower QoL in patients with a variety of health disorders [27-29], in psychiatric outpatients
[30] and in middle-aged adults [31]. Duberstein et al [32] found that this relationship prevailed even
after controlling for observer-rated depression and objective indicators of medical burden.
Neuroticism has also been found to affect the subjective components of health-related QoL in older
adults [33]. Results concerning the remaining three personality factors are less consistent; some
suggest a link between high Conscientiousness and better quality of life [23, 31, 34], and others
suggest a limited and inconsistent role for Openness [32, 35] and Agreeableness [23]. Some studies
have suggested that gender differences in personality, notably the tendency for women to score
more highly on Neuroticism, might contribute to gender differences in both the perception of QoL
[36] and its interactions with personality [27].

The present study aimed to explore the determinants of quality of life in two groups of older adults
– one young-old and one old-old – for whom a range of past and concurrent demographic, medical
and psychological factors are available. The variables included here as determinants of quality of
life were based on those found in previous research, including personality traits (especially
Neuroticism) and mood state (especially depressive symptoms) which have been found to be
associated with perceived QoL alongside more objective factors such as health status, cognitive
ability, social class, and life circumstances. Importantly, the present study investigated the patterns
of associations present in two cohorts of older individuals of different ages, each of which was large
and homogeneous in age, and on whom the same data were available.

Method
Participants
The participants were from the Lothian Birth Cohort 1921 (LBC1921) or 1936 (LBC1936), both of
which have been described in detail elsewhere [37, 38]. Most participants had, at around the age of
11, taken part in one of the Scottish Mental Surveys (SMS), which took place in 1932 and 1947 [39,
40]. Conducted under the auspices of the Scottish Council for Research in Education, the Surveys
aimed to obtain a measure of the psychometric intelligence (using a modified version of the Moray
House Test (MHT) No. 12) of all Scottish schoolchildren born in 1921 or 1936 [39]. These surveys
represent 95% and 94% respectively of the whole available year-of-birth populations [41]. The
Lothian Birth Cohort studies were designed to follow up individuals from the SMSs who were
living in the Edinburgh area of Scotland in old age, to investigate the cognitive, psychosocial, and
physical ageing processes. Participants in both cohorts undertook an assessment in Edinburgh
consisting of: a comprehensive battery of cognitive tests (including repeat administration of the
MHT used in the SMS) and a structured interview relating to their health, occupation and lifestyle,
conducted by trained researchers; and an extensive physical examination conducted by trained
nurses.

The LBC1921 Study began in 1999 and consists of 550 (238 men) individuals who were living
independently and were first followed up at around age 79 [37]. At age 80-81, participants were
sent a questionnaire which included self-reported quality of life. In total, 497 questionnaires were
returned, 494 containing some information relating to QoL: 487 were complete and 7 were
incomplete, from which 4 gave enough information to calculate at least one domain score. Of those
who did not return this questionnaire, 8 had died in the intervening period, 7 had withdrawn from
the study, 29 returned a refusal to complete it, 1 questionnaire was returned as undeliverable, and
the remainder were not returned. At around age 81, those participants in the LBC1921 who had not
either died or withdrawn were sent the International Personality Item Pool (IPIP) Big-Five Factor
Markers 50-item questionnaire (see below). 467 IPIP questionnaires were returned: 450 were
complete, and 17 contained enough information to calculate scores on at least one domain.
The LBC1936 Study began in 2004 and consists of 1,091 individuals (548 men) living
independently in the Edinburgh area, who were first followed up at around age 70 [38]. At a clinic
visit, participants were given a questionnaire to return, which contained detailed questions about
personality (including the IPIP), quality of life, lifestyle, and demographic background. 967 of the
LBC1936 participants completed and returned at least part of the study questionnaire: 921
completed the entire questionnaire, 957 completed all the quality of life questions and a further 8
completed sufficient quality of life questions to calculate scores on at least one domain. 924
completed all the IPIP questions, and a further 37 completed enough of the IPIP questions to
calculate scores on at least one personality domain.

Ethical permission for the LBC1921 study protocol was obtained from the Lothian Research Ethics
Committee (LREC/1998/4/183). For the LBC1936 study ethics permission was obtained from the
Multi-Centre Research Ethics Committee for Scotland (MREC/01/0/56) and from Lothian Research
Ethics Committee (LREC/2003/2/29). The research was carried out in compliance with the Helsinki
Declaration. All participants gave their written, informed consent.

Measures
Quality of life
Quality of life was measured using the WHOQOL-BREF. The WHOQOL-100 Quality of Life
Assessment was developed by a group of World Health Organisation (WHO) collaborators to be
applicable cross-culturally [42-45]. The WHOQOL-BREF is an abbreviated version containing 26
questions, each representing one facet of the WHOQOL-100, as well as one facet on overall quality
of life, and one on general health. It produces scores for four domains related to QoL: physical
(physical health and functional status), psychological (psychological well-being), social
relationships (personal relationships and social support), and environment (living circumstances
including access to services). It has good validity, consistency and reliability [1].

One question (q21: How satisfied are you with your sex life?) was judged to be inappropriate for
the LBC1921 group at age 79. In consultation with the WHOQOL-BREF’s developers, it was
reworded in order to retain its usefulness within the social relationships domain as: ‘How satisfied
are you with the support you get from your family?’. The replaced item was rated the least
important in a cross-cultural validation study [46] and had elicited a poor response rate amongst a
group of institutional elderly [47] and older adults in Norway and Canada [48]. The altered question
was retained for the LBC1936. Principal Components Analysis of the LBC’s WHOQOL-BREF
responses revealed that this change had not altered the item structure of the social relationships
domain.

A pro-rating technique was used for missing items such that, where one item was missing from a
domain, it was replaced by the average score of the remaining items within that domain. Domain
scores were calculated from the mean score of items, following the protocol defined for the
WHOQOL-BREF [49].

Predictor variables
Predictor variables were chosen from the large amount of data available on the Lothian Birth
Cohorts that previous research had shown to be possible determinants of quality of life and that
were present in both cohorts.
Social class.
Participants were asked to provide their highest status occupation. This was used to calculate their
occupational social class using the Classification of Occupations that coincided most closely with
the peak of their careers – 1951 for the LBC1921 [50] and 1980 for the LBC1936 [51]. Social class
consists of five or six groupings: I (professional occupations), II (managerial and technical
occupations), III (skilled occupations, split within the 1980 classification into IIIN (non-manual)
and IIIM (manual)), IV (partly-skilled occupations) and V (unskilled occupations). Female
participants were asked for both their own and their husband’s occupations (as applicable) and the
highest of the two used to represent their social class.

Educational attainment.
Participants reported age at leaving full-time education and their highest educational qualification.
The former was used to calculate the number of years of full-time education received.

Cognitive ability at age 11 and in old age.

Almost all participants in the LBC1921 and LBC1936 studies were administered a modified version
of the Moray House Test No 12—a valid, group-administered cognitive ability test, with a 45-
minute time limit, and consisting mainly of verbal reasoning items—when they were aged about 11,
as part of the SMS1932 or 1947 [37]. The MHT was re-administered to the participants in the
LBC1921 and LBC1936 at a mean age of 79 and 70, respectively, using the same time limit and
instructions that were used in the SMSs. MHT scores were adjusted for age in days at the time of
testing, and converted an IQ-type scale which, by convention, has a mean of 100 and S.D. of 15.
This was done separately for youth and old age, and these were done separately within each of the
two LBC studies.

International Personality Item Pool (IPIP).

The IPIP Big-Five Factor Markers scale used here was the 50-item inventory [52]. This has
previously been validated in the LBC1921 [53] and has 10 items for each of the Big-Five
personality factors: Extraversion (E), Agreeableness (A), Conscientiousness (C), Emotional
Stability (ES; the same trait as Neuroticism, but named and scored from the opposite end of the
continuum) and Intellect/Imagination (I; similar to Openness to experience). For each of the items,
which are in sentence fragment form (e.g., "Am the life of the party"), "I" was added at the
beginning. Participants indicated how well each item described them, on a 5-point Likert-type scale
(from very inaccurate to very accurate).

Hospital Anxiety and Depression Scale (HADS) (continuous) [54].

The HADS contains 7 items each for anxiety and depression. The maximum score on each scale is
21, with probably significant anxiety or depression states traditionally indicated by scores of 11 or
over.

Cardiovascular disease history (Yes/No).

Participants in both LBC studies were asked during their initial clinic visit whether or not they had a
history of cardiovascular disease (including heart attacks, angina, and irregular heartbeats). This
was included as a self-reported indicator of health status.

Grip strength (continuous).

Grip strength was measured using a North Coast Hydraulic Hand Dynamometer (JAMAR). The
highest measurement achieved—from three trials—from the dominant hand was used as an
indicator of the health of the musculature and health status more generally, especially in old age
[55].

Living alone or not (Yes/No).

All participants were asked whether or not they lived alone at the time of their clinic visit.

Statistical analysis
All statistical analyses were carried out using the Statistical Package for the Social Sciences version
14.0. Principal Components Analysis was used to investigate the structure of the WHOQOL-BREF
for the two LBC groups. Cronbach’s Alpha coefficients were calculated to assess the internal
consistencies of the four quality of life domains. Some studies have highlighted the importance of
considering QoL in older adults at a facet rather than domain level [56, 57]. Therefore, PCA was
used to derive a general quality of life factor for each cohort from all 26 items of the WHOQOL-
BREF. This was used in addition to the four QoL domains as an outcome measure in all subsequent
analyses.
Pearson’s bivarate correlations between the predictor variables and quality of life measures were
calculated by cohort and sex. Where one variable is dichotomous and the other is continuous, these
are point-biserial correlations. Crawford’s test for significant differences between correlations [58,
59] was carried out to identify any differences in the pattern of associations between the two cohorts
and the two sexes. Significant (p<0.05) differences were observed between the two cohorts in 27 of
the correlations with a trend (.05<p<.10) on a further 14. The differences in sets of associations
observed between the two cohorts were judged possibly to reflect age-related changes and,
therefore, subsequent analyses were conducted on each cohort separately. Between the sexes there
were significant differences in only 9 of the correlations (13 showed a trend), which could be due to
chance.

Variables whose correlations were significant at the p<0.05 level in either cohort were entered in a
stepwise fashion into multiple linear regression analyses with each of the five QoL measures (the
four domains and the derived general factor) entered in turn as the outcome variable. We recognise
the possible danger of over-fitting, but we note here that we have two samples, each with a large
number of subjects and very good subject-to-variable ratios.

Results

Subject characteristics
Table 1 contains descriptive statistics for participants by cohort and sex on the predictor and
outcome variables. Significant cohort differences were found for: grip strength; HADS depression;
the physical, psychological and environment domains of the WHOQOL-BREF; and the general
quality of life factor. In all of these, the LBC1921 showed disadvantageous scores. The LBC1921
scored more highly on IPIP Agreeableness.

In both cohorts, females: had significantly weaker grip strength; greater levels of HADS anxiety;
higher scores on Agreeableness; lower psychological QoL; were significantly less likely to have a
history of cardiovascular disease; and more likely to live alone. Within the LBC1921, females had:
significantly lower old age IQ, years of education, and social class; and scored lower on the
environment domain and the general QoL factor. Within the LBC1936, females had: significantly
higher childhood IQ and social class; and scored higher on social QoL, and lower on IPIP
Emotional Stability.

Structure of the WHOQOL-BREF within the LBC

Principal Components Analysis of the 26 questions of the WHOQOL-BREF suggested that the item
structure of this measure in the Lothian Birth Cohorts recapitulates the four domains proposed by its
developers (results not shown). The internal consistencies of the domains of the WHOQOL-BREF
were very good: Cronbach’s α exceeded 0.7 for all four domains across both cohorts (see Table 2).
In the PCA there was a clear ‘general quality of life component’ to be found in the first unrotated
principal component of the WHOQOL-BREF’s items. This accounted for 33.5% of the variance in
LBC1921, and 30.7% of the variance in LBC1936. The mean loading of items on this general
component was .57 (range .72 to .36) in the LBC1921, and .55 (range .73 to .41) in the LBC1936.
The regression method was used to derive a score for each person on ‘general QoL’.

Associations and predictors of quality of life

The strength of association between variables was tested for each cohort using correlations
(Appendix Table). There were significant associations between the 5 measures of QoL used and
between the measures of QoL and most of the independent variables in both cohorts. Significant
correlations ranged from -.092 to -.536 in the LBC1921, and -.060 to -.565 in the LBC1936. The
highest correlations in each cohort were: between the QoL measures, suggesting a high degree of
overlap amongst these constructs; and between HADS depression, HADS anxiety, IPIP Emotional
Stability and the QoL measures. In both cohorts, childhood and old age IQ had strong associations
with the environment domain and lower or no associations with the other QoL measures. In the
LBC1921, the QoL general factor and the environment and social domains were significantly
correlated with most of the independent variables, whereas the psychological and physical domains
correlated the least with sociodemographic and cognitive variables. IPIP Intellect and
Agreeableness showed the weakest correlations with QoL. In the LBC1936, the QoL general factor
and environment domain were significantly correlated with all other variables. The social and
psychological domains were only weakly correlated with sociodemographic and cognitive
variables. Unlike in the LBC1921, the physical domain was significantly correlated with these
variables. IPIP Intellect and Extraversion showed the weakest of the personality trait correlations
with QoL.
The results of the regression analyses are shown in Tables 3 (LBC1921) and 4 (LBC1936). The
models account for between 46.4%/44.5% of the variance in the general quality of life factor and
19.7%/18.7% of the variance in the social domain. The presence of minor symptoms of depression
contributed the greatest amount of variance to the vast majority of QoL measures, the exception
being the environment domain in the LBC1921. Emotional Stability also had a large part to play in
most of the models. Agreeableness contributed significantly to the physical domain in the LBC1921
and the social domain in both cohorts. Conscientiousness contributed to the physical, psychological
and general factor in both cohorts and the environment domain in the LBC1936. Extraversion
contributed to the psychological domain in the LBC1921 and the physical domain in the LBC1936.
Intellect did not appear in any of the models. Social class and cognitive ability contributed to the
environment QoL domains in both cohorts. Overall, the LBC1921 models were simpler and
involved fewer variables than the LBC1936 models; note that the latter’s larger sample size was
able to detect smaller effects. Each model additionally incorporated independent variables making
contributions to particular domains of quality of life: e.g. cardiovascular disease history (physical
domain); living alone (social), and social class (environment). Of particular interest is the general
QoL factor, which the models suggest is predicted by HADS depression, Emotional Stability,
cardiovascular disease history, living alone, and Conscientiousness, and additionally in the
LBC1921 by social class, and additionally in the LBC1936 by HADS anxiety and old age IQ.

Discussion

The WHOQOL-BREF demonstrated good reliabilities for all four domains, in keeping with other
studies [48, 57]. Significant and large correlations were observed between the four QoL domains,
again supporting previous research [56, 57]. This justifies our considering QoL in older adults at the
facet level through a general QoL factor. The presence of minor psychological symptoms of
depression and lower levels of IPIP Emotional Stability played a large role in determining self-
reported QoL in old age. Current depression contributed the greatest amount of variance in QoL in
both cohorts (except the environment domain in the LBC1921), and Emotional Stability made a
significant contribution in all models. The validity of the data was supported by the presence in
each model of additional contributing factors that made conceptual sense to that domain. For
example, in both cohorts, CVD history predicted physical health and general QoL, personality traits
predicted psychological QoL, living alone and Agreeableness predicted social QoL, and social class
and old age IQ (both of which may lead to higher income levels and therefore a better quality of
home environment) predicted environment QoL.
Our findings support those of Blane et al. [16] that past demographic factors have little effect on
QoL. Childhood IQ did not predict QoL in the LBC1921 and had only a small predictive role to
play in the physical and social domains of the LBC1936, with a similar result being observed for
years of education. Social class did play a part in predicting some aspects of QoL in both groups;
however, as this was occupation-based, it could be a reflection of their current financial
circumstances. The lack of association between childhood cognitive ability and QoL in the
LBC1921 regression analyses contradicts Bain et al’s findings in a similar cohort [6] but mirrors the
findings of Gow et al. [60], who reported that satisfaction with life in this group was unrelated to
childhood IQ. However, there were bivariate associations between childhood IQ and the
environment and social domains in the LBC1921, and with physical, environment and general QoL
in the LBC1936. These appear to have been mediated by other factors later in the lifecourse.

This study supports the findings of previous studies that personality and mood factors predict QoL
over and above other, more objective factors [29, 33, 35, 61]. Depressive mood state plays a
particularly important role in these groups, as does the personality trait Emotional Stability, both of
which corroborate previous research [6, 32]. A degree of caution is needed here, however, as the
strong association between mood state and the Emotional Stability trait suggests they may well be
measuring a similar construct, sometimes called negative affectivity [62]. Nevertheless, both have
been shown to have a considerable impact on an individual’s approach and response to life
circumstances and may well have separate but important roles to play in influencing QoL. Our
findings with the other personality traits were mixed. They support the suggestion of others that
high Conscientiousness may lead to improved QoL [23, 31, 34], with Conscientiousness appearing
as a predictor in all but the social domain in both cohorts, but don’t support a role for Extraversion
or Openness (Intellect). Agreeableness has largely been overlooked in the literature to date;
however, our results suggest that it may influence particularly social QoL. The presence of
personality traits amongst other factors with a more direct influence on quality of life in our models
support the suggestion that personality has a buffering effect on associations between life
circumstances and QoL [33].

A strength of this study was the inclusion of two groups of individuals who possess similar
demographic characteristics but are at different stages in the ageing process. Previous research has
suggested that an individual’s approach to life circumstances alters with age [7, 17, 18], and this is
largely supported here. Within the LBC1921, the number of predictors for each of the QoL
measures is lower than within the LBC1936. This is probably due to the larger size of the younger
group, enabling the analysis to pick up more subtle effects. It could in part be due to a greater
degree of heterogeneity inherent in the LBC1936. The determinants of quality of life are also
slightly different, with living alone exerting more of an influence on the various measures than in
the LBC1921. Again, this makes conceptual sense, as a smaller percentage of the LBC1936 lived
alone and so this factor may have more impact in early old age. This is in keeping with previous
studies which have suggested a crucial role for social relationships and support in predicting QoL
[21].

This study has limitations. Our focus on healthy, independently-living older adults inevitably
restricts the variability of the group, along with the tendency for research participants to be of
higher average intelligence [63]; the mean score on this test for the members of the two LBC groups
at age 11 was higher than that of the population as a whole (LBC1921: 46.4 (S.D. 12.0) vs 34.5
(15.5); LBC1936: 49.0 (11.8) vs 36.7 (16.1) [40, 41]). This therefore restricts the applicability of
our models to the general population. However, other studies of the determinants of quality of life
have also suggested that models may be population-specific [21]. Another potential limitation is the
timing of our measures: the measurement of QoL and personality were not exactly concurrent with
each other or the measurement of old age cognition and physical health in the LBC1921, although
this was rectified in the LBC1936. Another limitation to our study was the inclusion of health- and
socioeconomic-related items within the WHOQOL-BREF. Some researchers argue that QoL
measures ought ideally to be separate from factors which may influence them [16, 64], including
current health and socioeconomic status. This was partly dealt with in the separate consideration of
each of the four domains of the WHOQOL-BREF, which each measure a different aspect of QoL.
In addition, the intrinsic links between an individual and their culture and life circumstances mean it
can be difficult to disentangle the interrelationships between personal and socioeconomic factors
when considering QoL [20] and so it is perhaps impossible to design a measure that does not
include any factors that may influence QoL. Finally, along with most other studies in this area, our
study was cross-sectional rather than longitudinal in nature, rendering it difficult to identify the
effects observed as age-related changes or cohort effects [14]. However, we are following up the
LBC1936 every three years and so, when they are 79, we shall be able to compare them with the
LBC1921 at the same age, and with themselves at age 70.

These results have implications for considerations of quality of life in older adults. Firstly and most
importantly, the strong relationship between depressive mood and QoL suggests that any
intervention aimed at improving an individuals’ functional status needs to incorporate
improvements in their mental health in order to increase their subjective well-being. Secondly, the
role of personality traits needs to be considered. Individuals high in Neuroticism (low on Emotional
Stability) are more likely to over-report physical symptoms and to experience negative emotions in
response to difficult circumstances and consequently report a lower QoL [62]. However, the
converse may be true: those low in Neuroticism may under-report symptoms and report a higher
QoL than their circumstances might suggest. Thirdly, interventions designed to improve QoL in
older people need to take into consideration individual differences in approaches and responses to
life circumstances and how these impact on perceived quality of life. Fourthly, there appear to be
differences in the determinants of QoL in young-old and old-old adults, suggesting that these
associations change with age. Finally, there are suggestions here that environmental quality of life
might be dependent rather more on material (i.e. financial) than psychological resources.
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Table 1: Subject characteristics by cohort and sex
LBC1921 LBC1936
Male (N = 238) Female (N = 312) Cohort (N = 550) Male (N = 548) Female (N = 543) Cohort (N = 1091)
Age 11 IQ 99.5 (15.5) 100.4 (14.6) 100.0 (15.0) 99.0 (15.9) 101.0 (14.0)* 100.0 (15.0)

Old age IQ 101.8 (14.7) 98.7 (15.1)* 100.0 (15.0) 100.5 (15.5) 99.5 (14.4) 100.0 (15.0)

Years of education 11.3 (2.8) 10.7 (2.2)** 10.9 (2.5) 10.8 (1.2) 10.7 (1.1) 10.7 (1.1)

Social class 2.1 (0.9) 2.3 (0.9)* 2.2 (0.9) 2.4 (0.9) 2.3 (0.8)* 2.3 (0.8)

Grip strength 34.7 (7.4) 20.6 (4.5)*** 26.5 (9.1) 37.6 (7.5) 21.6 (5.2)*** 29.6 (10.3)***

HADS Anxiety 4.6 (3.1) 5.6 (3.4)*** 5.2 (3.3) 4.2 (2.9) 5.6 (3.3)*** 4.9 (3.2)

HADS Depression 3.6 (2.2) 3.5 (2.4) 3.5 (2.3) 2.9 (2.3) 2.7 (2.1) 2.8 (2.2)***

IPIP Extraversion 29.9 (7.7) 31.2 (7.3) 30.7 (7.5) 31.0 (7.3) 31.7 (6.9) 31.3 (7.1)

IPIP Agreeableness 39.8 (5.0) 43.2 (4.8)*** 41.8 (5.2) 39.0 (5.4) 43.1 (4.6)*** 41.1 (5.4)*

IPIP 38.6 (6.1) 38.8 (6.1) 38.7 (6.1) 38.0 (5.9) 38.5 (6.1) 38.2 (6.0)
Conscientiousness
IPIP Emotional 34.8 (8.5) 33.9 (7.8) 34.2 (8.1) 35.5 (7.6) 33.8 (7.6)** 34.6 (7.7)
Stability
IPIP Intellect 33.9 (6.0) 33.4 (5.8) 33.6 (5.9) 33.8 (5.8) 33.9 (5.6) 33.8 (5.7)

QoL Physical 14.9 (2.9) 14.8 (2.7) 14.8 (2.8) 16.1 (2.6) 16.1 (2.6) 16.1 (2.6)***

QoL Psychological 15.5 (2.1) 15.1 (2.0)* 15.3 (2.1) 15.8 (1.8) 15.5 (1.8)* 15.7 (1.8)***

QoL Social 17.4 (2.2) 17.2 (2.5) 17.3 (2.4) 16.7 (2.4) 17.3 (2.4)* 17.1 (2.4)

QoL Environment 16.8 (1.9) 16.2 (2.2)** 16.5 (2.1) 16.7 (1.9) 16.7 (1.8) 16.7 (1.8)*

QoL general factor -.084 (1.0) -.28 (1.1)* -.20 (1.1) .10 (.96) .10 (.93) .10 (.94)***

History of CVD† 22.4 11.5** 16.2 28.3 20.8** 24.6***

Lives alone† 29.9 61.4*** 48 15.5 33.4*** 24.4***

Means (S.D); † percentages are shown for these variables. * = significant at 0.05; ** = significant at 0.01; *** = significant at 0.001.
Asterisks adjacent to the female columns = male-female differences, & adjacent to the LBC1936 cohort column indicate cohort differences.
The QoL general factor was derived using Principal Components Analysis of all 26 items of the QoL scale used.
QoL = Quality of Life; LBC = Lothian Birth Cohort; HADS = Hospital Anxiety and Depression Scale; IPIP = International Personality Item Pool; CVD = Cardiovascular Disease.
Table 2: Internal consistency indicated by Cronbach’s α for WHOQOL-BREF domains by cohort

Domain LBC1921 LBC1936 All

Physical 0.848 0.849 0.853
Psychological 0.768 0.729 0.747
Social 0.729 0.752 0.743
Environment 0.787 0.769 0.772
General QoL 0.914 0.903 0.907
LBC = Lothian Birth Cohort
The QoL general factor was derived using Principal Components Analysis of all 26 items of the WHOQOL-BREF.
Table 3. Lothian Birth Cohort 1921 linear regression analyses

QoL Domain Predictor Unstandardised Standard Standardised P value R squared

β error β change
Physical HADS depression -.453 .055 -.391 .000 .215
IPIP Emotional Stability .084 .016 .243 .000 .062
R2 = .322 History of CVD -.441 .115 -.168 .000 .024
IPIP Agreeableness -.075 .026 -.139 .004 .010
IPIP Conscientiousness .052 .022 .114 .018 .011

Psychological HADS depression -.334 .035 -.389 .000 .287

IPIP Emotional Stability .079 .010 .317 .000 .125
R2 = .447 IPIP Conscientiousness .045 .013 .136 .001 .019
Grip strength .020 .008 .093 .015 .008
IPIP Extraversion .025 .011 .092 .023 .007

Social HADS depression -.179 .048 -.191 .000 .097

IPIP Emotional Stability .058 .014 .208 .000 .048
R2 = .197 Live alone .599 .204 .139 .004 .018
IPIP Agreeableness .067 .022 .153 .002 .020
Old age IQ .020 .008 .122 .013 .014

Environment Social Class -.645 .114 -.270 .000 .136

HADS depression -.236 .042 -.264 .000 .107
R2 = .305 IPIP Emotional Stability .055 .013 .204 .000 .048
Old age IQ .021 .008 .132 .007 .014

General factor HADS depression -.167 .017 -.402 .000 .303

IPIP Emotional Stability .040 .005 .320 .000 .108
R2 = .464 Social class -.149 .044 -.135 .001 .017
Live alone .229 .075 .120 .002 .012
History of CVD -.105 .037 -.111 .005 .013
IPIP Conscientiousness .018 .007 .111 .007 .011
Notes: QoL = Quality of Life; HADS = Hospital Anxiety and Depression Scale; IPIP = International Personality Item Pool; CVD = Cardiovascular Disease.
The QoL general factor was derived using Principal Components Analysis of all 26 items of the WHOQOL-BREF.
Table 4. Lothian Birth Cohort 1936 linear regression analyses

QoL Domain Predictor Unstandardised Standard Standardised P value R squared

β error β change
Physical HADS depression -.389 .037 -.325 .000 .201
History of CVD -1.401 .176 -.228 .000 .058
R2 = .325 IPIP Emotional Stability .063 .011 .187 .000 .040
IPIP Conscientiousness .050 .013 .116 .000 .012
Grip strength .020 .007 .077 .007 .006
Age 11 IQ .013 .005 .072 .013 .004
IPIP Extraversion -.023 .011 -.063 .030 .004

Psychological HADS depression -.289 .023 -.350 .000 .273

IPIP Emotional Stability .055 .008 .233 .000 .104
R2 = .423 Live alone .482 .106 .115 .000 .016
HADS anxiety -.095 .019 -.170 .000 .014
IPIP Conscientiousness .040 .008 .132 .000 .016

Social HADS depression -.228 .037 -.209 .000 .092

IPIP Agreeableness .080 .015 .182 .000 .042
R2 = .187 Live alone .947 .177 .170 .000 .024
IPIP Emotional Stability .054 .010 .174 .000 .021
Age 11 IQ -.011 .005 -.068 .032 .004
Sex .340 .165 .072 .039 .004

Environment HADS depression -.180 .028 -.218 .000 .127

Old age IQ .017 .004 .133 .000 .051
R2 =.245 IPIP Emotional Stability .027 .009 .115 .004 .032
Social Class -.177 .076 -.080 .020 .011
IPIP Conscientiousness .034 .009 .114 .000 .010
HADS anxiety -.059 .023 -.104 .010 .006
Education .143 .057 .089 .012 .006
Live alone .258 .128 .061 .044 .004

General factor HADS depression -.179 .013 -.393 .000 .309

IPIP Emotional Stability .029 .004 .225 .000 .080
R2 = .445 History of CVD -.302 .061 -.129 .000 .016
IPIP Conscientiousness .021 .004 .128 .000 .016
Live alone .255 .060 .109 .000 .012
Old age IQ .006 .002 .078 .003 .007
HADS anxiety -.024 .011 -.077 .025 .003
Notes: QoL = Quality of Life; HADS = Hospital Anxiety and Depression Scale; IPIP = International Personality Item Pool; CVD = Cardiovascular Disease.
The QoL general factor was derived using Principal Components Analysis of all 26 items of the WHOQOL-BREF.
 [Appendix Table] Correlations between the variables of interest in the LBC1921 (above the diagonal) and the LBC1936 (below).
Sex Age 11 Old age Social Educ- HADS HADS Grip IPIP E IPIP A IPIP C IPIP ES IPIP I QoL QoL QoL QoL L
IQ IQ class ation anxiety dep. strength physical psych social enviro Q
fa
LBC1921 QoL -.09* .06 .22** -.22** .17** -.39** -.54** .18** .25** .11* .24** .44** .11* .82** .85** .65** .81** --
factor
QoL environment -.13** .21** .31** -.38** .26** -.28** -.36** .18** .19** .14** .13** .31** .19** .49** .59** .57** ---- .7
QoL social -.05 .13** .20** -.15** .13** -.25** -.33** .09 .20** .18** .14** .28** .06 .29** .56** ---- .43** .6
QoL psychological -.09* -.01 .14** -.07 .05 -.38** -.52** .17** .31** .11* .28** .48** .10* .59** ---- .56** .54** .8
QoL physical -.02 -.05 .11* -.11* .10* -.30** -.44** .14** .13** -.01 .18** .35** .03 ---- .53** .28** .47** .8
IPIP I -.04 .32** .22** -.20** .29** -.07 -.18** .12* .28** .29** .16** .03 ---- .02 .10** .06 .16** .1
IPIP ES -.06 .11* .21** -.10* .19** -.48** -.29** .15** .28** .09 .20** ---- .08* .36** .48** .25** .31** .4
IPIP C .02 -.00 .00 .06 -.07 -.19** -.19** .02 .16** .31** ---- .21** .18** .22** .26** .12** .20** .2
IPIP A .32** .07 -.03 .01 .00 -.07 -.24** -.23** .39** ---- .30** .12** .28** .09 .18** .26** .13** .2
IPIP E .08 -.08 -.08 -.04 .03 -.11* -.26** -.01 ---- .29** .09** .19** .37** .06 .19** .12** .15** .1
Grip strength -.77** .03 .20** -.14** .18** -.21** -.03 ---- -.03 -.27** .04 .13** .01 .14** .13** -.02 .13** .1
HADS Depression -.02 -.02 -.09* .07 -.10* .39** ---- -.06* -.21** -.22** -.21** -.36** -.11** -.47** -.53** -.31** -.35** -.
HADS Anxiety .16** -.10* -.16** .09 -.10* ---- .37** -.24** -.15** .05 -.09** -.61** -.04 -.30** -.46** -.19** -.32** -.
Education -.12** .44** .42** -.48** ---- -.08* -.09** .09** .11** -.01 -.03 .10** .22** .10** .02 -.03 .20** .1
Social class .10* -.41** -.36** ---- -.45** .05 .07* -.01 -.12** -.06 -.04 -.12** -.21** -.09** -.05 -.00 -.21** -.
Old age IQ -.10* .66** ---- -.34** .39** -.19** -.14** .13** .08* .07* .07* .18** .26** .18** .13** .04 .29** .2
Age 11 IQ .03 ---- .69** -.38** .42** -.13** -.11** .02 -.10** .06 .04 .14** .29** .14** .03 -.01 .25** .1
Sex ---- .07* -.03 -.08** -.01 .22** -.04 -.78** .05 .37** .04 -.11** .01 -.00 -.07* .08** -.00 .0
Note: N ranges between 405 and 548 for LBC1921 and between 897 and 1090 for LBC1936.
*p<.05; **p<.01
LBC = Lothian Birth Cohort; QoL = WHOQOL-BREF Quality of Life; IPIP (International Personality Item Pool): I = Intellect; ES = Emotional Stability; C = Conscientiousness; A =
Agreeableness; E = Extraversion; HADS = Hospital Anxiety and Depression Scale.
The QoL general factor was derived using Principal Components Analysis of all 26 items of the WHOQOL-BREF