QUALITY OF LIFE OF SENIORS STAYING IN THE VASCULAR SURGERY DEPARTMENT

Introduction

A growing group of researchers explore patients’ quality of life (QoL). The topic is gaining more and more importance in medical science, mainly due to the desire to implement holistic treatment that takes into account all aspects of patients’ health. As a result, an increasing number of studies on this issue can be seen in the literature. Increasingly, it is not only the biological assessment of the patient’s condition itself that is being studied but also, and more importantly, the patient’s well-being, emotions, acceptance of the disease or ability to function in daily life [1,2].

There are many definitions of the QoL, which can be categorized into two groups: professional definitions formulated by experts, which include global, complex, specific and mixed scales, and colloquial terms. The global scales are concerned with assessing QoL as a whole, i.e. overall life satisfaction, well-being in various spheres of life and a sense of happiness. Complex definitions take into account partial areas of human life in addition to the global assessment, and the assessment of such partial areas affects the global QoL. In turn, specific definitions focus on specific areas of life. This group includes the definition of health-related QoL, which is determined by the subjective assessment of health and consequences of an illness and its symptoms. The last group, i.e. mixed scales, takes into account the global assessment of QoL and, in addition, also external factors such as living environment, economic conditions, social participation and the person’s individual expectations. Colloquial definitions, on the other hand, are presented by researchers, for whom QoL is a subjective concept so it is impossible to capture it in the form of norms or standards [3].

One of the earliest definitions of QoL was developed by Rourke and Dalkey in 1972. According to them, QoL consists of two elements: satisfaction with life and the feeling of happiness. Authors of definitions developed later approached the problem even more broadly. In 1987, Torrence noted that QoL should define the totality of a person, in all his/her existential dimensions [4]. In the same year, Walden-Gałuszko developed a Polish definition of QoL, referring to the personal assessment of one’s position in life, which should be made over time and taking into account the respondent’s recognized hierarchy of values. It can also be defined as the difference between real conditions and the situation expected by the individual [5].

As an example of how important QoL has become in recent times, the World Health Organization (WHO) has decided to create its definition, which points out that good QoL is not only about the absence of diseases but also about good mental, physical and social well-being, which is of great importance for the health of the individual. This definition indicates that QoL should be viewed holistically, taking into account clinical, psychological and social conditions in juxtaposition with the external environment. Therefore, QoL cannot be equated with concepts such as “health status”, lifestyle, life satisfaction, mental status or well-being [6].

Attempts to clarify the definition of QoL in medicine led to the creation of a new concept in 1993, namely Health Related Quality of Life (HRQoL). Over time, the WHO modified its original definition, recognizing that QoL is “an individual’s perception of his or her position in life within the cultural context and value system in which he or she lives and in relation to the tasks, expectations and standards set by environmental conditions” [7,8]. A year later, Schipper, Patrick, Guayaff and Spillker created a standardized questionnaire for assessing QoL [5], which took into account a patient’s functioning in the physical (mobility), emotional and social spheres, as well as the patient’s symptoms and the effects of treatment. Proponents of this definition included Leppert, Floryska and de Walden-Gałuszko, who noted that, in addition to the factors mentioned above, one should take into account the patient’s attitude toward themselves and their illness, and how they cope with problems in order to globally assess the patient’s QoL [6].

As a result, there are three elements to consider when studying health-related QoL:

According to Stecler [9], there are many facets to understanding QoL but the important thing is that the concept refers to those dimensions that are crucial to the patient in question. These include physical problems (symptoms, pain), the ability to function (activity), satisfaction, emotionality, spirituality, social functioning, satisfaction with treatment, future orientation, sexuality, intimacy and interests [6,9].

Based on the definition developed by the WHO in 1997, Orley and Saxena distinguished several elements that affect QoL. These include mental state, relationships with other people, living environment, physical health and level of independence [6]. Siegrist and Junge also believe that QoL involves several interrelated elements, including physical indicators (disability, pain), psychological conditions (mood, degree of anxiety, depressive states) and social conditions (isolation, ability to perform social roles) [10].

Researchers agree that the overall evaluation of QoL should not be based on one factor only as it is the result of various subjective and objective elements. Therefore, depending on the different criteria adopted in QoL evaluation in research and clinical practice, two aspects are taken into account: the subjective and the objective one [7].

Any disease disrupts a person’s functioning by affecting his or her QoL in many areas. It can change the person’s social roles, force them to give up their career or limit social contacts. It often entails pain, suffering, shatters one’s sense of security, causes isolation or reduces well-being due to a sense of unfinished business in life, eventually leading to low mood and even depression [9].

According to data reported by the Central Statistical Office (CSO), cardiovascular diseases have for many years been one of the most important health problems in Polish society and are the leading cause of death [11,12]. Despite increasingly better diagnostics and modern treatments, about 200,000 people die from them every year in Poland. In our country, the problem is primarily a high incidence of disease the causes of which are called risk factors. People with several such factors, which include old age, low physical activity, overweight and obesity, poor diet, smoking, impaired glucose tolerance, psychological factors (excessive stress, depression) or cases of heart disease in the family are particularly vulnerable to the development of cardiovascular disease. Many authors of scientific studies on the QoL of patients with cardiac diseases published in leading cardiology journals (Annals of Thoracic Surgery, Arteriosclerosis, Thrombosis and Vascular Biology, British Heart Journal, Cardiology, Circulation, Kardiologia Polska, Folia Cardiologica Excerpta) demonstrate that certain procedures introduced in the treatment of cardiac patients that alleviate their troublesome symptoms, increase their QoL (e.g. ablation, implantation of a ventricular pacemaker, Cox Maze III procedure, surgery of the ascending aorta and aortic valve), which seems to be the rationale for addressing QoL issues and ongoing analyses [13].

The most important causes of cardiovascular disease are uncontrolled hypertension, lipid disorders, smoking, low physical activity, poor diet and carbohydrate disorders [14-16]. Cardiovascular diseases are much more common in patients with diabetes, with impaired lipid and glucose metabolism [15]. Pathological changes lead to tissue ischemia, which is caused by narrowing or complete closure of the arterial lumen [14,16]. This causes various types of symptoms that patients complain of, such as severe pain and coldness in the extremities, lack of peripheral pulse, change in skin color, superficial and deep sensibility disturbances, collapse of superficial veins, ischemic muscular contractures, edema, intermittent claudication, acute tissue ischemia or necrosis occur later [17,18]. All of them can contribute to the lowering of patients’ QoL.

Aim of the work

The purpose of the paper is to evaluate the QoL of patients hospitalized in vascular surgery departments. As reported in the literature, QoL is as important as the results of physical, laboratory and clinical tests. Therefore, it seems reasonable to study health-related QoL in this group of patients in order to assess the effectiveness of the treatment and therapeutic process.

Material and methods

The study included 227 patients with a diagnosed vascular disease, staying in the Vascular Surgery Department at the Jan Mikulicz-Radecki University Clinical Hospital in Wroclaw, Poland. In the analysis, A proprietary questionnaire was used containing questions on socio-demographic data (including age, gender, education, place of residence, number of medications taken, treatment of low mood) and standardized, international, reliable and accurate questionnaires:

The Beck’s questionnaire is often used in scientific research as well as in clinical practice as a tool to help diagnose and monitor the severity of depressive symptoms. However, it is only a screening tool and is not used to make a diagnosis. Therefore, consultation with a specialist is required [20].

Inclusion criteria for the study consisted of a diagnosed vascular disease, health adequate to complete the questionnaire, and being in a vascular surgery department.

The significance of differences between the two mean values was tested using the Student’s t test for independent samples. Correlations between variables were checked using Spearman’s rank correlation coefficient. This coefficient takes values from +1 (strong positive correlation), through 0 (no correlation) to -1 (strong negative correlation). A significance level of p<0.05 was adopted. Analyses were performed using SPSS software.

Results

The majority of the respondents were male (119; 52.42%). The largest group of respondents was over the age of 60 (150; 66.08%), followed in order by the 51-60 age group (43; 18.94%), 41-50 (21; 9.25%) and the 30-40 age group (13; 5.73%). They were mainly people with secondary education (84; 37.00%), followed by vocational education (70; 30.84%), higher education (59; 25.99%) and primary education (14; 6.17%), from cities with more than 100,000 residents (110; 48.46%).

The respondents usually lived with a spouse (145; 63.88%), less often alone (52; 22.91%), with children (26; 11.45%) or another person (4; 1.76%).

Most respondents took 3 to 5 medications (84; 37.00%), slightly fewer took up to 2 medications (73; 32.16% ) or more than 5 (70; 30.84%) and, in addition, 18 people (7.93%) were treated for low mood.

The average score for the QoL index was 41.4 points with a standard deviation of 20.30 points. At least half of the respondents scored at least 42.1 points. The distribution of the variable ranged from 7.7 to 82.6 points. The respondents’ QoL was worse in the physical dimension (M=45.6 points, SD=24.31 points). At least half of the respondents scored at least 46.6 points for this dimension. The distribution of the variable ranged from 3.9 to 92.2 points.

The mean for the mental dimension was 35.1 points, with SD=18.70 points. At least half of the respondents scored at least 35.3 points. The lowest QoL score was reported for the general health scale (49.3) and for the pain scale (48.1), and the highest ones for the social function scale (31.2) and emotional limitations scale (31.3) (Table 1).

The analysis using Spearman’s rank correlation coefficient showed a statistically significant relationship between age and the grades for physical functioning (p<0.001), physical limitations (p=0.007), general health (p =0.033), emotional limitations (p=0.013), mental health (p=0.016), physical dimension of QoL (p<0.001), and the SF-36 QoL index (p=0.004). Older respondents were more likely to experience reduced QoL in terms of physical functioning, have greater physical and emotional limitations, general health problems, and lower QoL in terms of physical and general health but their mental health was better than in the case of younger respondents.

It was also found that respondents with higher levels of education were less likely to have problems with physical functioning (p=0.013), with physical limitations (p=0.004), had lower scores for SF-36 (p=0.014) and for the physical dimension of QoL (p=0.004). In addition, respondents living in rural areas and small towns were more likely to experience lower QoL in terms of their mental health (p=0.038).

Respondents taking more medications were more likely to experience reduced quality of physical functioning (p<0.001), more likely to have physical (p=0.003) and emotional limitations (p=0.002), more problems with general health (p=0.003) and with vitality (p=0.042). They also scored high (low QoL) on the overall SF-36 questionnaire score (p<0.001) and for the physical (p<0.001) and mental (p=0.021) dimensions (Table 2).

An analysis using the Student’s t test for independent samples showed that women (SD=54.1) were significantly more likely than men (SD=42.7) to experience reduced QoL due to pain (p=0.007) (Table 3).

There was also a significant difference in terms of experienced pain (p<0.05) between those living alone and those living with someone; single people reported higher QoL in this regard (Table 4).

Those respondents who were treated for low mood scored higher (lower QoL) for the SF-36 questionnaire (p =0.043) and for its mental dimension (p=0.004). They also had a lower QoL in terms of general health (p =0.040), social functions (p=0.003), emotional limitations (p=0.006), and mental health (p=0.043) (Table 5).

The mean score obtained for the BDI was 10.6 points with SD=8.85 points. At least half of the respondents scored at least 9 points and the distribution of the variable ranged from 0 to 42 points, so nearly 57% of the respondents had no depression, 36% of the respondents experienced a depressive episode of mild severity, the rest experienced a depressive episode of moderate severity.

Correlation analysis using Spearman’s rank correlation coefficient showed a statistically significant association between the BDI and the respondents’ education (p=0.021) and the number of medications they were taking (p<0.001). Those with higher levels of education and taking fewer medications had lower scores on the BDI (Table 6).

The study found no statistically significant differences between men and women in the BDI scores (p =0.584), and no similar relationship was demonstrated for analyses between living alone or with others and the BDI (p=0.752). However, statistical analysis using Spearman’s rank correlation coefficient demonstrated statistically significant associations between the BDI and the SF-36 questionnaire scores for all its dimensions and subscales. The higher the level of depression among the respondents, the lower their QoL was (Table 7).

Discussion

Our own research has shown that men are more likely to suffer from vascular diseases than women. Similar results were obtained in the research conducted by Papłaczyk and Gawor [21], Czuchryta and Kowalski [22], and Spannbauer and Madejczyk [23]. In turn, Raciborski et al. [24] demonstrated that vascular diseases are more common in women than in men. This result was obtained after examining 301 patients, 260 of whom were women. Although it is men who show a greater predisposition to vascular disease incidence, the reasons for this are not fully established and require further research [25].

The research conducted for this paper showed that the majority of patients in the vascular surgery department are over 60 years old. These data coincide with those collected by Krosny and Dąbek [26] and by Spannbauer and Madejczyk [23], who demonstrated that the largest percentage of those qualified for vascular procedures were patients in the 45-78 age range. Based on the results, it can be concluded that vascular diseases affect the elderly more often. The most common reason for their occurrence is atherosclerosis, which is often called the “silent killer” due to its nearly asymptomatic progress in its early stages [27].

The results also showed that nearly half of the respondents with vascular disease lived in large cities. These data are in line with the study by Raciborski et al. [24]. It seems that the higher incidence of the disease among people living in larger cities results from location-specific factors such as higher levels of stress, a stressful lifestyle or exposure to other external factors that predispose to the development of atherosclerosis and, consequently, increased incidence of vascular disease. In addition, large agglomerations are also characterized by high emissions of air pollutants, which, according to Modrzejewski, are one of the factors affecting the development of cardiovascular disease [28].

The majority of respondents reported taking 3 to 5 medications on a regular basis. This result is in line with those obtained by other researchers. For example, Ksiądzyna and Szeląg demonstrated in their analysis that most cardiac patients take between 3 and 8 medications a day. The patient’s age should also be taken into account as it predisposes them to an increased incidence of multiple morbidities and thus multiple medications, which may reduce their QoL [29].

Another variable examined for the purposes of this study involved analyzing whether respondents experienced low mood or even symptoms of depression. Humańska et al. proved that the onset of depressive states is observed more often in those who live alone. Reasons for this may include loneliness as well as family conflicts or estrangement [30]. However, our own research did not confirm such a trend, and statistical analysis showed no significant differences in the incidence of depression between single people and those living with their families. Perhaps the situation results from the fact that most of the respondents lived in large cities and therefore had frequent opportunities for contact with other people. However, it seems that further analysis is needed to explain the results obtained.

The study shows that the lowest QoL was found for the scales of general health and pain. This confirms the fact that pain significantly affects a person’s well-being, especially if it is chronic, which is the case for many seniors. In particular, pain restricts mobility and the efficiency of activities, makes the patient care-dependent, which undoubtedly affects the patient’s mental well-being. Research by Domżał demonstrated that depression is the most common psychological reaction resulting from chronic pain [31]. This was confirmed by the results obtained from our own research, which proved that the lower the QoL of the respondents was, the higher the score was for depression.

Muszalik’s research demonstrated that patients over 65 are significantly more likely than younger people to have mobility difficulties, as well as decreased vitality needed to undertake daily activities and more pain [30]. Similar results were obtained by Low et al., thus demonstrating that the QoL decreases with age [32].

Proprietary research found that reduced QoL was mainly experienced by elderly respondents. This was especially true with regard to limitations in physical and emotional functioning, as well as general health. Interestingly, elderly respondents had a higher QoL in terms of mental health than younger people. A similar result was obtained in the analysis by Rustoen et al. [33], confirming that higher QoL is experienced in the older age group. Papłaczyk et al. and Repka obtained different results in this regard, demonstrating that there was no correlation between age and QoL of the respondents [21,34].

The study also found that the quality of mental health depends on where respondents live: people from rural areas and small towns experience lower QoL in this regard. Unfortunately, no information on this relationship was found in the literature. However, it is possible to hypothesize that the reason for reduced QoL in terms of mental health is an unsatisfactory material situation, including low satisfaction with housing conditions or anxiety over insufficient finances. Elderly patients with multiple morbidities may ask themselves whether they will be able to cope with the expenses related to the diagnostics, treatment and rehabilitation, as well as home adaptations to their changing needs [35].

The results show that women were more likely than men to experience low QoL due to pain, which is consistent with the literature. Similar results were obtained by Paplaczyk et al. who proved that women rated the intensity of their pain higher than men. The author claims that the perception of QoL and health depends largely on the severity of pain, so the greater the pain, the worse the perception of quality [21]. Żółnieczuk-Kieliszek came to similar conclusions in her study, demonstrating the difference in QoL depending on the gender of the respondents. In her study, women scored lower on the mental and physical pain scales compared to men [36].

Analyzing the results obtained from the BDI, it was found that most of the respondents did not have symptoms of depression. Depressive episodes were only observed in a few of them. It is suspected that the reason for this situation is that medical developments and innovative surgical techniques are increasing the chances of successful procedures and therefore prolonging the patient’s life. A cardiac patient has a good chance of being cured currently unlike, for example, patients with advanced cancer. This information can make a big difference in terms of patients’ well-being and positively affect their QoL [37]. Therefore, it can be concluded that low mood and potential depression depend on the diagnosed condition among other things. In addition, many exogenous and endogenous factors influence its possible appearance, including, for example, the patients’ character, whether they rely only themselves or can count on the help of other people, that is, how extensive their social networks are [38]. Nowadays, depression is a rather frequently discussed topic. According to the research, e.g. by Humańska or Ostrzyżek, depression is an increasingly common problem for the elderly. According to the authors, depressive syndromes are the most common mental syndromes, and are a significant problem in the elderly, primarily due to the significant deterioration of their QoL, which is not the best anyway [30,39]. Interestingly, the degree of acceptance of the disease, and therefore the mood of the patients, depends on their education. Kurlak and Dacka demonstrate in their analysis of patients diagnosed with abdominal aortic aneurysm that respondents with higher education are more accepting of the disease than those with vocational, secondary or primary education [11]. A similar relationship was proved by Szyguła-Jurkiewicz [40], which coincides with the results of our own study based on the SF-36 questionnaire. The relationship in question appears to be related to patients’ greater awareness of their own condition. They also show more determination in seeking information about the nature of the disease, its treatment and possible complications.

The present study also demonstrated the relationship between education, the BDI and the number of medications taken. Respondents with higher education took fewer medications and scored lower on the Beck scale. Not having to take medications can mean not having a disease, and therefore entail a lower risk of depression. However, it should be remembered that the body’s natural aging process has already begun in people over 65 years of age, which can lead to multiple morbidities and the use of multiple medications, so the risk of depression may increase [41].

Humańska et al. [30] demonstrated a statistically significant relationship between emotional well-being and perceived QoL among the elderly in their study. The higher the score was on the GDS scale, the significantly lower the respondents’ sense of QoL. This confirms the principle that depressive states entail limited contact with people and reduced social activity [30]. Proprietary research confirms this correlation, which was demonstrated using the BDI and the SF-36 questionnaire. The higher the respondents’ level of depression was, the lower their QoL.

Today’s medicine strives for holistic care provided to the patient and the restoration of the best possible health of the patients so that they have a chance to achieve maximum independence, fitness and autonomy. Helpful in achieving this goal is the determination of the patient’s QoL, i.e., their subjective assessment of their emotional well-being, health, social and physical states, providing an opportunity for appropriate selection and course of therapy. It is important to approach each patient on an individual basis, taking into account their participation in the measures taken [42].

As evidenced by numerous studies, assessing the QoL of people with cardiovascular diseases is as important as the results of physical, laboratory and clinical examinations. Therefore, it seems reasonable to study health-related QoL in this group of patients, which can help improve the efficiency of the treatment and therapeutic process [13].

Conclusions