SZ Hussein*, K Norazilah, H Rosnita
Universiti Kebangsaan Malaysia (UKM), Malaysia
*Corresponding Author’s Email: zuhaida_hussein@yahoo.com
ABSTRACT
Life at mature ages is perceived to be very challenging and mostly influenced by the aging process and negative changes which increase the risk of functional abilities. The most enormous thing to achieve is to live independently with less help from others to achieve optimum quality of life. Methods: This is a community-based cross-sectional survey conducted among 414 community-dwelling older adults in Pontian District aiming to identify the functional status and to examine the relationship between functional status and three types of loneliness. The Pfeffer Functional Activities Questionnaire was used to measure the level of functional status. Loneliness was measured with the short form of Social and Emotional Loneliness Scale for Adults. All data were analyzed using Statistical Package for Social Science Ver.26 for windows. The results of this study show that the mean (+SD) age is 71.4(+2.0). The majority of respondents perceived good health status and no deterioration of functional status. 8.2% of respondents experienced deterioration in functional status. Of these, 32.6% of respondents experienced social loneliness; 39.9% experienced emotional loneliness, and 9.2% experienced family loneliness. The results also revealed a significant relationship between functional status and social loneliness (p = 0.02). In conclusion, the majority of respondents are independent to perform functional activities and less than half of them are experienced with social, emotional and family loneliness. Deterioration of functional in the older adults was associated with social loneliness. This study may help in improving the care of older adults to live independently and freely in the community.
INTRODUCTION
Living independently and freely in the community remains a goal of successful aging. The essential part that allows living independently is when the older adults are capable of performing necessary or desirable basics and instrumental tasks in their daily living (Singh et al., 2014). In this regard, functional status is one of the most important indicators of optimum quality of life among older adults (Sharma 2020; Singh et al., 2014; Burman 2019; Pinto et al., 2016). A previous study reported the majority of older adults who live in the community to have high functional status and are able to live independently (Pinto et al., 2016). They are able to perform several self-care tasks of daily living such as feeding, walking or dressing and able to perform the instrument activities for their living included performing the housework as well as managing finances (Singh et al., 2014). In other words, older adults are classified as totally independent.
Nevertheless, the result of Ajayi et al., (2015) study was in contrast to previous studies. Almost 88% of older adults in their study had functional disabilities which they needed assistance to perform basic activities of daily living. Besides that, lack of personal hygiene and grooming
are the highest functional impairment experienced by Nigeria older adults (Ajayi et al., 2015). The study showed a significant association between the deterioration of functional disability and increasing age, polygamous families, and lack of formal education (Ajayi et al., 2015). In the Burman et al., (2019) study, about fifty percent of Indian elderly were dependent on others to do at least one of the activity daily living and out of that a quarter were greatly dependent for instrumental functional activities.
Currently, many studies have been conducted focusing on the influence of functional status, physical activity, and quality of life among older adults. A study carried out by Parra-rizo and Sanchis-Soler (2020) reported autonomy in functional and subjective well -being is closely related to the practice of physical activity among the older adults. As yet, Sharma (2020) and Burman (2019) have identified the functional status is negatively correlated with old age, female, depression, and chronic illness. With regard to the quality of life, the higher levels of functional disability are associated with mobility and quality of life in older adults (Baptista et al., 2018). Indeed, older adults who had chronic diseases are prone to have a lower functional status in which the main problem is a restriction of mobility, decreased physical health, and fragility.
Referring to previous studies, it was found that high scores of loneliness among Turkish older adults who require dependence on daily activities either in need of full or partial assistance to meet the needs of daily activities (Hacihasanog˘lu & Karakurt 2011). Furthermore, loneliness and functional status were reported to have a statistically significant relationship. Nonetheless, Perissinotto, Stijacic, and Kenneth (2012) found the percentage of older adults who are dependent on daily activities also had experienced loneliness. Meanwhile, Guo et al. (2020) highlighted those older women who experienced social isolation significantly have deteriorating functional status. However, Guo et al., (2020) reported loneliness had no significant relationship with functional status deterioration.
Due to the continuing growth of the older adult population in contemporary society, the concern on how to continue and improve functional abilities has become a crucial public health issue. The key reason is to encourage them to live independently in the community. However, there is a limited published study examining the functional status among the older adults residing in Pontian. Therefore, this study was conducted to identify the functional status of older adults in the Pontian district.
METHODOLOGY
This study is a cross-sectional community-based survey of 414 community-dwelling older adults living in the Pontian District. This design was selected in accordance with the provision of data that complements each type of method that was used which can generate more meaningful data. A proportional stratified random sampling method was utilized in this study, and all information was collected through questionnaires. All the older adults were identified by a door-to-door census and participated voluntarily in the study.
Instrument
In this study, the level of functional status was measured with Pfeffer Functional Activities Questionnaire (PFAQ) developed by Pfeffer et al. (1982)-passive voice. This instrument maintained a good validity with Cronbach Alpha values between 0.72 and 0.74. This instrument consists of 10 items, ranging from scale 0 (independent) and scale 3 (dependent) which assess the functional status of the older adult in carrying out their daily activities. The cut-off point is 9 and if the total score exceeds nine or the person is fully dependent on performing three (or more) daily activities; it indicates deterioration in the functional status. Level of loneliness was measured by the Short Version of Social and Emotional Loneliness Scale for Adults (SELSA-S) that was developed by DiTommaso and Spinner (1993). The SELSA-S had good validity with the test-retest of was 0.88 for the social loneliness, 0.83 for emotional loneliness and 0.91 for family loneliness domain. The SELSA-S consists of 15 items and was translated into the Malay language in this study. The translated version has a good internal consistency of 0.87 and 0.90. The scoring for loneliness was categorized to ‘Yes’ and ‘No’.
Statistical Analysis
The data were analyzed using SPSS Statistics 26.0 for Windows in accordance with the purpose of the study and the characteristics of the variables. The significant level was set at P<0.05. Descriptive statistics like frequency tests and inferential analyses such as chi-square were used.
RESULTS
Demographic Characteristics
The socio-demographic characteristics of the respondents in this study are displayed in Table 1. The result of this study showed the majority of respondents were Malays (77.1%) followed by Chinese (22.2%) and Indian (6%). A total of 257 (62.1%) of the respondents was women. The majority of respondents are at the age of 65 to 75 olds (71.7%). The mean (+SD) of age was 71.4 (+2.0). The level of education of 44.4% of respondents attend primary education, 22.2% secondary school, 15.3% tertiary level education and only 75 (18.2%) are not in school. Furthermore, 65.9% of respondents were married, 27.1% widowed and only 8% were single. Over 40.3% of respondents living with a partner, 36% lived with their children and grandchildren, and 23.7% lived alone.
The results also revealed 57% of respondents did not have chronic diseases, and 90.8% perceived they had good health status. Meanwhile, 32.6% of respondents had social loneliness; 39.9% had emotional loneliness and 9.2% had family loneliness.
(N = 414)
Variables | Frequency (n) | Percentage (%) | Mean (+SD) |
Age 60 - 74 years 75 - 84 years 85 years and above | 297 92 25 | 71.7 22.2 6.0 | 71.4 (+2.0). |
Gender Male Female | 157 257 | 37.9 62.1 | |
Ethnic Malay Chinese | 319 92 3 | 77.1 22.2 0.7 |
India | |||
Level of education Not schooling Primary education Secondary education Tertiary education | 75 184 92 63 | 18.1 44.4 22.2 15.3 | |
Marital status Single Married Divorce/ separate Widower | 5 273 21 112 | 1.9 65.9 5.1 27.1 | |
Living Arrangement Alone With husband/wife/partner With children/grandchildren | 98 167 149 | 23.7 40.3 36.0 | |
Chronic Diseases No Yes | 178 236 | 43.0 57.0 | |
Perception on health status Bad Good | 38 376 | 9.2 90.8 | |
Social loneliness No Yes | 279 135 | 67.4 32.6 | 3.4 (+1.3) |
Emotional loneliness No Yes | 249 165 | 60.1 39.9 | 3.6 (+ 1.2) |
Family loneliness No Yes | 376 38 | 90.8 9.2 | (+1.2) |
Functional Activities and Status
In this study, the result showed more than 80% of respondents are independent to perform basic daily living activities. The results of the study also showed 25(6%) of respondents need full assistance for traveling out to the neighborhoods, driving, arranging to take buses and 4.8% of respondents also require full assistance in remembering appointments, family occasions, holidays, medications. Meanwhile, 10.1% of respondents need a partial assistant to perform writing checks, paying bills, or balancing a checkbook and 9.7% of respondents need partial assistance to perform shopping alone for clothes, household necessities, or groceries.
Furthermore, the results of this study showed 34(8.2%) respondents experienced deterioration in the functional status.
Functional abilities | Independent | Has difficulty, but does by self | Partial Assistan ce | Full Assistance /dependent |
n(%) | n(%) | n(%) | n(%) | |
Writing checks, paying bills, or balancing a checkbook | 337(81.4) | 25 (6.0) | 42(10.1) | 10(2.4) |
Assembling tax records, business affairs, and other papers | 373(90.1) | 12 (2.9) | 19( 4.6) | 10(2.4) |
Shopping alone for clothes, household necessities, or groceries | 331(80.0) | 16 (3.9) | 40( 9.7) | 27(6.5) |
Playing a game of skill such as checkers or chess, working on a hobby | 368(88.9) | 34 (8.2) | 5(1.2) | 7(1.7) |
Heating water, making a cup of tea, turning off the stove | 392(94.7) | 8 (1.9) | 8(1.9) | 6(1.4) |
Preparing a balanced meal | 335(85.7) | 27 (6.5) | 24(5.8) | 8(1.9) |
Keeping track of current events | 369(89.1) | 25 (6.0) | 8(1.9) | 12(2.9) |
Paying attention to and understanding a TV program, book, magazine | 371(89.6) | 26 (6.3) | 4(1.0) | 13(3.1) |
Remembering appointments, family occasions, holidays, medications | 334(80.7) | 42 (10.1) | 18(4.3) | 20(4.8) |
Travelling out to neighborhood, driving, arranging to take buses | 337(81.4) | 38 (9.2) | 14(3.4) | 25(6.0) |
Deterioration of Functional Status No Yes | 380 (91.8%) 34 (8.2%) | 2.49 (+3.82) | ||
Relationship Functional Status and Lonelines
The results of this study revealed the social loneliness experienced by 17 (50%) respondents with a deterioration of functional status while 52.9% of respondents experienced emotional loneliness. The result showed a significant relationship between social loneliness with functional status (χ² = 5.10, df1; p=0.02).
Types of Loneliness | Functional Status | χ² | P Values | |
No Deterioration n (%) | Yes, Deterioration n (%) | |||
Social Loneliness No Yes | 262(69.0) 118(31.0) | 17(50.0) 17(50.0) | χ² = 5.10 | p=0.02 |
Emotional Loneliness No Yes | 233(61.3) 147(38.7) | 16(47.1) 18(52.9) | χ² = 2.65 | p =0.10 |
Family Loneliness No Yes | 347(61.3) 33(08.7) | 29(85.3) 5(14.7) | χ² = 1.36 | p =0.24 |
df1; p<0.05
DISCUSSION
This study was conducted to identify the level of functional status and its relationship among the dwelling older adults in Pontian District. The overall result showed the majority of respondents were Malays and at the age of 65 to 75 old, married and only 23.7% lived alone. Meantime, the majority of respondents had no deterioration of functional status. This means that most of older adults in this study are able to live independently and productively in the community.
Additionally, they practice self-care and independently to perform basic routine activities as well as instrumentally functional activities in the community. This situation is expected because the majorities of respondents at the age of 65-75 are still active and can achieve anything they desire. This result is similar to previous studies where the middle-old person is capable of performing the activities of routine life without outside help (Baptista et al. 2018, Pinto et al., 2020; Parra-rizo & Sanchis-Soler 2020). Pinto et al., (2020) stated that most respondents at the age of middle-old categories are independent in carrying out the activities of daily living. In contrast, Ajayi et al. (2020) reported that older adults aged 60 and above who are attending the primary health care clinic are experienced functional disabilities. The functional problems experienced by the elderly have caused them to need full support in meeting daily needs. For example they needs support in performing at least one of the components of basic activity of daily living like transferring from bed to chair and preparing meals.
The result of this study stated that few of the respondents need full assistance in several activities such as shopping alone for clothes, doing household necessities or groceries and traveling out to the neighborhoods. In the researcher's opinion, this situation may be influenced by whether they did not own reliable transport, or they cannot drive due to obscuring vision. Indeed, the public transport in Pontian is not efficient. Another reason it may be because older adults are not particular to go shopping or grooming. Studies show older adults, who perform a high level of physical activities, are able to perform daily life activities with little difficulty. Hence, this situation increases the satisfaction of life apart from optimizing the level of autonomy for older adults. Studies highlighting the highest level of functional status are among the older adults (Parra-rizo & Sanchis-Soler 2020, Baptista et al. 2018). Parra-rhizo & Sanchis- Soler (2020), emphasized those with high functional status are able to perform physical activities without the help of others and this situation provides optimal self-satisfaction in elderly individuals. Moreover, individuals with high life satisfaction are associated with better health and longevity. Indeed, it could lower risk of mortality. However, this relationship was not statistically significant. Meantime, Baptista et al. (2018) explained that higher levels of functional disability are among older adults with limited mobility or in a state of mobility. Indeed, this ability can lower their quality of life.
The result of this study showed barely 40% of respondents’ experienced emotional loneliness and less than 33% of respondents experienced social loneliness. Out of that, respondents who had deterioration in functionality experienced more emotional loneliness followed by social loneliness and family loneliness. However, merely social loneliness is significant with functional status. This situation is predicted due to people who had deterioration in functional status who is physically not capable or had limited physical health. Hacihasanog˘lu and Karakurt (2011) pointed out that the older adults who need fully assistant in performing basic routine activities were state precisely as factors that increase the level of loneliness. Furthermore, loneliness associated with a reduced level of functionality including basic activities and activities instrumental function (Perissinotto, Stijacic & Kenneth 2012). Based on this result, Perissinotto, Stijacic, and Kenneth (2012) concluded the deterioration of functional status among older adults had an impact on the increasing level of loneliness. A previous study reported the functional disability was significantly associated with loneliness at the primary analysis only but not significant at the logistic regression analyses (Guo et al. 2020). In Guo et al. (2002) study, the functional disability was significantly associated with loneliness among the elderly person but was not for women. Anyhow, previous longitudinal studies show that there is no significant relationship between loneliness and functional status even after adjusting for all variables control (Stessman et al. 2014). The researchers highlighted that the potential impact of loneliness on functional status and optimal health may be overrated if the study does not take into account the social relationships (Guo et al. 2020).
CONCLUSION
In conclusion, a sufficient number of vulnerable elderly in Pontian do not experience deterioration in functional status. A functional status only had a significant relationship with social loneliness.
This study undoubtedly had its own strength and may help in improving the care of older adults. Moreover, this study was community-based, and the respondent was selected from a study population of several villages in the Pontian district.
The limitations of this study are related to a limited sample of older adults living in certain districts in Malaysia. In addition, the design of the cross-section in this study is only provided information about the current state of experience, but cannot explore more in-depth about loneliness. Therefore, the results of this study could be generalized to the elderly in Malaysia. For suggestions, more studies should be implemented in large populations within a varied environment with several types of functional status among older adults. The longitudinal study was recommended for further study to examine whether functional status affects loneliness and vice versa.
Conflict of Interest
The authors declare that they have no competing interests in writing this article.
ACKNOWLEDGMENT
We would like to acknowledge the Faculty of Medicine, Universiti Kebangsaan Malaysia (Project/C: FF-2013-300) and Pontian District’s Officer for their support in achieving this work.
REFERENCES
Ajayi, S.A., Adebusoye, L.A., Ogunbode, A.M., Akinyemi, J.O. & Adebayo, A.M. (2015). Profile and correlates of functional status in elderly patients presenting at a primary care clinic in Nigeria. Africa Primary Health Care Family Medicine. 7(1): 810. https://doi.org/10.4102/phcfm.v7i1.810
Baptista, F. M., Rodrigues, A.M., Gregorio, M.J, de Sousa, R. Cruz. E. & Canhao H. (2018). Functional Status and Quality of Life Determinants of a Group of Elderly People with Food Insecurity. Frontier in Nutrition. Vol 5(99). https://doi.org/10.3389/fnut.2018.00099
Burman, J., Sembiah, S., Dasgupta, A., Paul, B., Pawar, N., & Roy, A. (2019). Assessment of poor functional status and its predictors among the elderly in a rural area of West Bengal. Journal Mid-life Health. 10(3):123-30. PMCID: PMC6767957. https://doi.org/10.4103/jmh.JMH_154_18
DiTommaso E. & Spinner, B. (1993. The development and initial validation of a measure of social and emotional loneliness (SELSA). Personality and Individual Differences (14):127- 134. https://doi.org/10.1016/0191-8869(93)90182-3
Guo L., An L., Luo F.P & Yu B. (2020). Social isolation, loneliness and functional disability in Chinese older women and men: a longitudinal study. Age and Ageing. 1-7. https://doi.org/10.1093/ageing/afaa271
Hacihasanog˘lu, R. & Karakurt, P.A. (2011). Loneliness in elderly individuals, level of dependence in activities of daily living (ADL) and influential factors. Archives of Gerontology & Geriatric 54(1):61-66. https://doi.org/10.1016/j.archger.2011.03.011
Parra-Rizo, M.A. & Sanchis-Soler, G. (2020). Satisfaction with Life, Subjective Well-Being and Functional Skills in Active Older Adults Based on Their Level of Physical Activity Practice. International Journal Environmental Research Public Health. 17(4):1299. https://doi.org/10.3390/ijerph17041299
Perissinotto, CM., Stijacic, C. & Kenneth, E.C. (2012). Loneliness in Older Persons: A predictor of functional decline and death. Achieves of Internal Medicines. 172(14):1078-1084. https://doi.org/10.1001/archinternmed.2012.1993
Pfeffer, R.I., Kurosaki, T.T., Harrah, C.H. Jr., Chance, J.M., & Filos, S. (1982). Measurement of functional activities in older adults in the community. Journal of Gerontology. 37(3):323- 329. https://doi.org/10.1093/geronj/37.3.323
Pinto, A.H., Lange, C., Pastore, C.A., Patricia Mirapalheta Pereira de Llano, Denise, Przylynski Castro & Fernanda, dos Santos. (2016). Functional capacity to perform activities of daily living among older persons living in rural areas registered in the Family Health Strategy. Cien Saude Colet. 21(11): 3545-55. https://doi.org/10.1590/1413-812320152111.22182015
Sharma, R. (2020). Functional Status, Social Support and Quality of Life as Determinants of Successful Aging. Gerontology & Geriatrics.
Singh, N., Kumar, S., Muzammil, K., Raghav, SK., & Singh, JV. (2014). Assessment of functional status in the elderly persons in the rural area of Punjab. Indian Journal of Community Health. 26 (1):25-9.
Stessman, J., Rottenberg, Y., Shimshilashvili, I., Ein-Mor, E., & Jacobs, JM. (2014). Loneliness, health, and longevity. Journal of Gerontology A Biol Sci Med Sci. 69: 744–50. https://doi.org/10.1093/gerona/glt147