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Aim: ‘Successful aging’ in individuals with schizophrenia has been attracting attention. We examined two forward-looking factors of successful aging among schizophrenia patients: ‘attitude toward aging’ and ‘preparing behavior for old age’.
Methods: Fifty-seven middle-aged and elderly schizophrenia patients with successful aging were identified using the Attitude toward Aging Scale, the Preparing Behavior for Old Age Scale, and assessments of their cognitive function, psychiatric symptoms, social functioning and quality of life. A multiple regression analysis was used to detect determinants of attitude toward aging/preparing behavior for old age at that time (‘present’: community dwelling). We also analyzed predictors of successful aging using demographic/clinical data assessed 3 years previously (‘past’: residential care).
Results: The multiple regression analysis revealed that quality of life was a significant determinant: a higher quality of life was related to a more positive attitude toward aging and less active preparing behavior. The significant predictors of preparing behavior were quality of life and the length of the hospital stay: a longer hospital stay and a higher quality of life were related to less active preparing behavior.
Conclusion: Quality of life and the length of the hospital stay significantly contributed to forward-looking factors of successful aging. Avoiding long hospitalization periods for patients with schizophrenia may lead to more active preparing behavior, but the improvement of quality of life may not be a sufficient condition. As schizophrenia patients have an optimistic attitude and insufficient preparing behavior, support to prepare such individuals for old age is required as part of community-based psychiatric care strategies.
THE CIRCUMSTANCES OF psychiatric care have changed considerably globally. Long-term hospital treatments have been replaced by community-based services that focus on supporting independent daily life and employment. Meanwhile, psychiatric services still remain predominantly hospital-based in Japan. A decline in hospital beds has been observed since 1994, but the total number of inpatient beds is still much larger (2.7 per 1000 people) than the numbers in the UK and the USA (0.7 and 0.3, respectively).1
The earliest large-scale project to enable a total transition from a psychiatric hospital to a residential facility in Japan was established in 2002 and was known as the Sasagawa Project, held in Koriyama, Fukushima.2,3 During the first stage of the project, 78 patients with schizophrenia who had been inpatients at Sasagawa Hospital for long time periods underwent 1 year of psychosocial training according to the protocol outlined by the Optimal Treatment Project (OTP).4,5 The patients were then discharged from the mental hospital and transferred to a supported residential facility, called Sasagawa Village, following the closure of the hospital in March 2002. During the second stage, the patients gradually left the residential facility and moved into the neighboring community in 2007, where they mainly lived in 19 group homes and several apartment houses (Fig. 1). They attended a day-care center, a community care support center, and the ‘I Can’ program and received nursing care visits. Some of the patients began supported job training. However, even though the patients had resumed their own daily living activities, they were already approaching old age. Thus, ‘successful aging’ may be a key concept in their community-based psychiatric care.
The concept of successful aging has grown in sociology, and it emphasizes that growth during senescence is more important than the decline caused by aging. Successful aging is influenced by lifestyle, rather than inherited characteristics, and it is a multidimensional concept that includes physical, psychological and social environmental factors.6 That is to say, successful aging is a bio-psycho-social adaptation to the changes that occur during aging.
Although aging with chronic diseases has been considered as pathological aging in the field of medicine and age-related function declines as during normal aging, Rowe and Kahn advocated dividing normal aging into usual and successful aging: individuals belonging to the former category showed typical non-pathologic and age-linked losses, while those belonging to the latter category showed fewer or no functional losses.7 They defined successful aging according to three main components: low probability of disease and disease-related disability, high cognitive and physical capacity, and active engagement with life.8
Several studies have been conducted since Rowe and Kahn's study. Depp et al. reported that although no consensus exists for the definition of successful aging, most of the definitions of successful aging included components that could be described as disability/physical functioning, cognitive functioning, life satisfaction/well-being, and social/productive engagement.9,10 Vaillant et al. suggested that successful aging in an individual's seventies could be predicted by variables assessable before the age of 50.11 Baltes et al. demonstrated greater functional losses of everyday functioning in the non-successful aging group than in the successful aging group.12 Cohen et al. demonstrated that older outpatients with schizophrenia showed favorable outcomes upon symptom remission (49%) but lower favorable levels upon community integration (23%) and for subjective (13%) and objective (2%) successful aging, compared with similarly aged peers.13
Although some previous medical studies have examined successful aging, few studies have used a subjective definition of successful aging14 or have dealt with the successful aging of individuals with schizophrenia. Previous studies on successful aging have mainly examined the existing condition at that time-point. The measures of successful aging were also simple and fundamental in the previous studies.
The selective optimization with compensation (SOC) model for successful aging focuses mainly on how people optimize resources and aids that facilitate success and compensate for losses to adapt to changes throughout their lives and to create an environment for lifelong successful development. In the SOC model, Ouwehand et al. argued that proactive coping aimed at preventing potential threats to goals is important for successful aging.15
The present study focuses on two forward-looking factors of successful aging in individuals with schizophrenia: ‘attitude toward aging’ and ‘preparing behavior for old age’. The ‘attitude toward aging’ factor refers to a subjective awareness of one's forthcoming later life and is based on the expected social situation and the prospects of one's own aging.16 To prepare for the achievement of a satisfactory and suitable later life, coping with the aging process should start during middle age. The ‘preparing behavior for old age’ factor refers to voluntary and objective conduct that is performed to prepare for various difficulties during one's old age.17 Having a proper perspective on old age seems to be an important factor in the successful aging of individuals with schizophrenia living in the community. To identify means of supporting such individuals, researchers must be aware of the attitude of these patients toward aging and their preparing behavior for old age. However, these issues have not been widely studied in individuals with schizophrenia.
In this study, we first examined successful aging in individuals with schizophrenia using the two forward-looking factors mentioned above. Second, we identified the determinants of the present and predictors at the past points and ascertained the change in patients after transitioning from residential facility care to community dwelling, which influenced the attitudes toward aging and preparing behavior.
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The mean score on the Preparing Behavior for Old Age Scale was 9.35 (SD = 2.02) and that on the Attitude toward Aging Scale was 5.12 (SD = 2.61). Cronbach's coefficient alpha of the Preparing Behavior for Old Age Scale was 0.611 and that of the Attitude toward Aging Scale was 0.693.
Table 1 shows that the mean age was 56.7 years at the time of the past evaluation. The mean number of days of hospitalization was 9061.0 (24.8 years) at the time of the past evaluation and 9090.0 at the time of the present evaluation (after discharge, some of the patients with schizophrenia briefly entered a hospital once again).
Table 1. Changes in demographic/clinical variables after transition from residential care to community dwelling (n = 57)
| ||Present (community-dwelling)||Past (residential care)|
|Length of hospital stay (days)||9090.0||3576.1||9061.0||3560.3|
As shown in Table 2, testing of the correlations between attitude toward aging/preparing behavior for old age at the time of the present evaluation and various factors revealed that the Preparing Behavior for Old Age Score was significantly correlated with the lengths of the hospital stay (negative correlation, r = −0.326, P < 0.05) and the WHOQOL26 average score (negative correlation, r = −0.518, P < 0.001), while the Attitude toward Aging Score was significantly correlated with the WHOQOL26 average score (positive correlation, r = 0.377, P < 0.05).
Table 2. Pearson coefficients for correlations between preparing behavior for old age/attitude toward aging and demographic/clinical variables at the times of the present and the past evaluations (n = 57)
|Preparing behavior for old age||Attitude toward aging||Preparing behavior for old age||Attitude toward aging|
|Lengths of hospital stay||−0.326*||−0.068||−0.327*||−0.067|
A stepwise multiple regression analysis using demographic/clinical variables as determinants was generated for both the attitude toward aging and the preparing behavior for old age to identify determinant variables most closely associated with the outcome variables at the present. Table 3 shows that the model for the preparing behavior for old age using variables obtained at the time of the present evaluation was significant and included only the WHOQOL26 average score as a determinant. This means that a higher QOL was related to less active preparing behavior for old age. The model for the attitude toward aging using variables obtained at the time of the present evaluation was also significant and included the WHOQOL26 average score. This means that a higher QOL was related to a more positive attitude toward aging at the time of the present evaluation.
Table 3. Stepwise multiple regression models for attitude toward aging/preparing behavior for old age with demographic/clinical variables at the time of the present evaluation as determinants and at the time of the past evaluation as predictors
| ||Dependent variable||Independent variables||Beta||P-value|| |
|Present||Preparing behavior for old age||WHOQOL26||−0.505||<0.001||(F = 18.457; df = 1, 56; P < 0.001; R2 = 0.241)|
|Attitude toward aging||WHOQOL26||0.319||0.016||(F = 6.138; df = 1, 56; P = 0.016; R2 = 0.085)|
|Past||Preparing behavior for old age||WHOQOL26||−0.314||0.016||(F = 6.697, df = 2, 55; P = 0.003; R2 = 0.180)|
|Lengths of hospital stay||−0.324||0.013|
|Attitude toward aging||NA||–||–||–|
Table 2 shows that testing of the correlations between attitude toward aging/preparing behavior for old age at the time of the past evaluation and various factors revealed that the Preparing Behavior for Old Age Score was significantly correlated with the lengths of the hospital stay (negative correlation, r = −0.327, P < 0.05) and the WHOQOL26 average score (negative correlation, r = −0.315, P < 0.05).
Table 3 shows that a stepwise multiple regression analysis using data on the preparing behavior obtained at the time of the past evaluation was significant and contained two variables: the WHOQOL26 score and the length of hospitalization. These results mean that a longer hospitalized period at the time of the past evaluation was related to less active preparing behavior, and a higher QOL at the time of the past evaluation was related to less active preparing behavior. No model for attitude toward aging was significant.
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The determinants at the present evaluation (community-dwelling) and the predictors at the past evaluation (residential care) were detected using multiple regression analyses. The QOL related to both the attitude toward aging and the preparing behavior at the time of the present evaluation: a higher QOL was related to a more positive attitude toward aging and less active preparing behavior. The predictors of preparing behavior for old age were QOL and the length of the hospital stay: a longer hospitalized period and a higher QOL predicted less active preparing behavior.
Hiraoka17 studied healthy individuals aged 60 years or older using the Preparing Behavior for Old Age Scale. The scores for family relationship and economy were lower in our study, although the total score was comparable with that of the previous study. Usami16 examined middle-aged nurses using the Attitude toward Aging Scale. The scores for the medical and welfare preparedness, and intergenerational relationships in our study were clearly higher than those of the study by Usami. Thus, the features of preparing behavior and attitude toward aging in individuals with schizophrenia dwelling in the community seemed to differ from those of healthy individuals.
This study revealed a correlation between preparing behavior for old age and QOL in patients with schizophrenia: the higher the QOL, the less active the preparing behavior. This result was in contrast to the result obtained for healthy individuals. In a study of healthy individuals aged 35–64 years, significant associations between preparing behavior and life satisfaction, interpersonal relationships and social participation were observed, and no significant association between preparing behavior and age was seen.28
If healthy individuals are satisfied with their life, they behave with their future life in mind if they have a sufficient economic margin.17 In contrast, individuals with schizophrenia did not behave with the future in mind even if they were satisfied with their life. Our study clearly indicated higher attitude-toward-aging scores in the category of medical and welfare preparedness, interpersonal relationships and independent life compared with the results of the study by Usami.16 In other words, community-dwelling individuals with schizophrenia seemed to have a positive perspective on medicine, welfare and economy. In addition, the scores for category of family relationship and economy for the Preparing Behavior for Old Age Scale were lower in our study than in the study by Hiraoka.17 As welfare guarantees a minimum livelihood, the patients may not need to make an effort to prepare for their future lives.
On the other hand, general cognitive function assessed using the MMSE was not associated with preparing behavior in our study. Generally speaking, it is not surprising that schizophrenia patients with good cognitive function (that is, they have sufficient self-monitoring with regard to their life) can recognize difficulties with their current lives and may want to make an effort to provide for their future. Although the correlation between cognitive function, especially frontal lobe function, and QOL has been studied, no consensus has yet been established.29 Further investigation using a comprehensive neurocognitive test battery is needed.
Regarding the correlation between attitude toward aging and QOL, the result demonstrated that a high QOL was related to a positive attitude toward aging. This result means that if patients are satisfied with their present life, they can consider their later life from a positive perspective. This result generally concurs with the results of a previous study of healthy individuals.30 In the previous study, significant positive associations between attitude toward aging and well-perceived health, house possession, good life satisfaction, good economic status and extensive interpersonal relationships were observed. No significant associations between attitude toward aging and sex, generation, marital status or child bearing were seen. On the other hand, some individuals may have a positive attitude toward aging as a result of active lifestyles and a high QOL, as QOL and attitude toward aging were assessed simultaneously in the present evaluation.
Although we expected elderly chronic patients with schizophrenia and negative symptoms to have a negative attitude toward aging and poor preparing behavior, our findings indicated that psychiatric symptoms were not related to these two factors. Social functioning was also not relevant to attitude toward aging and preparing behavior in this study. Regardless of the levels of daily life activities, which were influenced by psychiatric symptoms, and social functioning, these actions might not be aimed at preparing for old age and thus might not be linked to preparing behavior. Also, the degree of psychiatric symptoms might not be essential for interest in old age.
In this study we examined the demographic/clinical variables at two time-points: the past (residential care) and the present (community-dwelling). The two different time-points have two meanings: the passage of time and the environmental change. The determinants for preparing behavior for old age differed between these two time-points. The length of the hospital stay was a predictor at the time of the past evaluation but was not a determinant at the time of the present evaluation, as shown in Table 3. This fact means that the passage of time after discharge might reduce the influence of a long hospital stay. A long hospital stay might tend to lead patients not to consider their future. However, dwelling in the community might diminish the influence of hospitalization. On the other hand, the difference in the influence on attitude toward aging at the two points was that no significant relevance to attitude toward aging was observed at the time of the past evaluation, while the QOL was a relevant variable at the time of the present evaluation. This result indicated that the attitude toward aging (subjective) was determined by the patients' circumstance, while the preparing behavior (objective) seems to have been influenced by recent lifestyle.
This study has several limitations. First, as Rowe and Kahn8 defined, the concept of successful aging generally includes mental and physical factors, but our research did not take physical factors into consideration. Second, not only the passage of time and environmental change, but also other factors, such as physical decline and social changes, might have occurred and influenced the attitude toward aging and preparing behavior for old age, although this study only investigated demographic/clinical variables. The influence of these factors, therefore, remains unknown.
Nowadays, many countries are experiencing an aging of society. In this study, we examined attitude toward aging and preparing behavior for old age as two of the key conditions of successful aging among schizophrenia patients who were approaching old age. The preparing behavior was significantly predicted by the length of the hospital stay at a short time after discharge from hospital, and only the QOL significantly contributed to preparing behavior after transfer to the neighboring community. This study suggests that avoiding long hospital stays may lead to a more active preparing behavior among individuals with schizophrenia; only improving the QOL may not result in preparing behavior, however it may lead to a positive attitude toward aging.
Studies on older adults with schizophrenia have found that a lower QOL is associated with clinical factors, such as depression, positive and negative symptoms, cognitive deficits, and poorer perceived health as well as social factors, such as unemployment, non-independent housing status, loneliness, lower social and living skills, financial strain, and acute stress. No significant association between age and QOL was observed in a previous study.31 Continued dwelling in the community seemed to have a better synergistic effect on self-reliance and life affluence and to improved QOL. Not only deinstitutionalization, but supporting community care is also crucial. As such, individuals have an optimistic attitude toward aging but do not have sufficient preparing behavior for old age. Continuous support to encourage preparing behavior, such as suggestions to save money for the future, are required.
With the progress of deinstitutionalization, the concept of successful aging, that is, not emphasizing a loss as a result of aging but focusing on gain and growth with aging, will become increasingly important globally in the development of strategies for the community-based psychiatric care of schizophrenia patients.