Vol.5, No.2, 212-221 (2013) Health
http://dx.doi.org/10.4236/health.2013.52029
Quality of life of elderly nursing home residents and
its correlates in Kayseri. A descriptive-analytical
design: A cross-sectional study*
Vesile Şenol1#, Ferhan Soyuer1, Mahmut Argün2
1H.B. Vocational School of Health, Erciyes University, Kayseri, Turkey;
#Corresponding Author:
2Department of Orthopedy and Traumatology, School of Medicine, Erciyes University, Kayseri, Turkey
Received 14 December 2012; revised 15 January 2013; accepted 22 January 2013
ABSTRACT
Purpose: To define the level of quality of life in
an elderly population and to investigate the ef-
fects of selected variables, such as anemia, fa-
tigue, depression and sleep disorders, on the
quality of life. Design and Methods: The study
was conducted in Gazioğlu Nursing Home, lo-
cated in the city center of Kayseri, on 136 sub-
jects ≥65 in the year 2008-2009. Data were col-
lected using the Geriatric Depression Scale
(GDS), Fatigue Severity Scale (FSS), Pittsburgh
Sleep Quality Index (PSQI) and the World Health
Organization Quality of Life-OLD (WHOQOL-
OLD) Module. In the statistical analysis mean ±
standard deviation, student’s t-test, ANOVA and
Spearman correlation analysis were used. Re-
sults: The mean total score of quality of life was
43.45 ± 10.30. Of the residents 47.0% had a poor
quality of life. Autonomy had the lowest (35.70 ±
19.96) and intimacy had the highest (48.75 ±
17.96) subdomain scores. Fatigue significantly
decreased the total and autonomy, social par-
ticipation and death and dying subdomain scores.
Anemia had a significant adverse effect on in-
timacy, depression on autonomy and intimacy
and sleep disorder on death and dying. There
were negative correlations between fatigue with
past-present-future activities and social partici-
pation, depression with social participation, in-
timacy, death and dying and glucose levels with
social participation and intimacy. Implications:
About half of the subjects had a poor quality of
life. Fatigue was the sole factor to negatively
affect the total score in WHOQOL-OLD. Depres-
sion, anemia and sleep disorder adversely af-
fected the autonomy, social participation, inti-
macy, death and dying subdomain scores but
not in all.
Keywords: Aged; Anemia; Fatigue; Depression;
Sleep Disorder; Quality of Life
1. INTRODUCTION
In recent years the average life expectancy has mark-
edly increased. It rose by 20 years between 1950 and
2000 to 66 years, and is expected to rise by another 10
years by the year 2050. Therefore, by the end of 20th
century, life expectancy had increased in the elderly
population and birth rates had decreased worldwide. This
strongly increased the percentage of people aged 65
years and over in the overall population [1,2]. In our
country, in parallel with global demographic transforma-
tion, the fertility rate decreased, mean life expectancy
has increased, and, as a result, the percentage of elderly
people in the overall population has rapidly increases.
In the elderly population, with prolonged life expec-
tancy, active aging, independence and the quality of life
experienced has become more important [1], because,
due to increased loss of function observed with senility, a
person becomes care-dependent and his need for care
increases. This need is generally met by familial mem-
bers and, especially, by the person’s children. However,
nowadays, the reduction in the family size/increase of the
immediate family in society, weakened familial bonds
and the increasing number of the women in the work-
force has reduced the number of the people who can as-
sume the care of the patients and elderly people. This has
given rise to the need for social assistance for increasing
numbers of elderly people and, therefore, the need for
institutionalization to meet the housing and care needs of
these people has become more important. In our country,
the provision of care for the elderly, which is lower
compared to that in developed western countries, due to
*We have no conflict interests.

V. Şenol et al. / Health 5 (2013) 212-221 213
cultural differences, is met by central government through
nursing homes. However, the qualitative and quantitative
standards of these institutions are controversial. Likewise,
in 2000, the number of patients per bed in a nursing
home was 16 in USA vs. 214 in our country [3]. Due to
decreased social assistance, elderly nursing home resi-
dents have a high risk of developing some psychological
disorders, such as isolation, self-depreciation and loneli-
ness, among which depression is the most commonly
seen problem. Therefore, nursing homes, which provide
institutional care for the elderly organized in such a way
as to take these problems into account.
In this regard, satisfaction surveys are strongly war-
ranted to reveal the quality of the services provided by
existing institutions. A quality of life evaluation of nurs-
ing home residents may be one of the best solutions to
this issue. To improve quality of life, an analysis of the
essential factors affecting life satisfaction is necessary.
Determination of individual, political, social and eco-
nomic factors, which may affect quality of life, will pin-
point high-risk elderly individuals and provide them with
more help and support.
It has been that quality of life was tends to be impaired,
with advanced age [4]. Based on the results obtained
from studies conducted to examine the quality of life in
the elderly population, which comprises an important
and problematic social group within the overall popula-
tion, life comfort is generally influenced by individual
sub-factors, such as physical health, functional status,
psychosocial and cognitive status and social communica-
tion, which are impaired with advanced age, as well as
by political, social and economic factors [5]. In these
studies, the main factors found to affect quality of life
included care dependency for daily life activities, dis-
ability, poor health status, advanced age, male gender,
life environment, functional limitations, marital status,
fatigue, sleep disorders, depression and the presence of
concomitant diseases [5,6].
According to the study conducted by Browne et al. [7]
while the most important quality of life determinants in
elderly people were “social activities, spare time activi-
ties and health”, the most important quality of life was
depressive mood based on the data of WHOQOL-OLD
obtained in Czech Republic [8]. In addition, the study
conducted by Low et al. [9] defined the determinants of
advanced-age quality of life as “health, financial status
and the meaning of life”. The main reasons for the dif-
ferences observed between age-related quality of life
scores were determined as “personal relations, health and
sexuality” [10].
In the light of the information also mentioned in this
study, we aimed to determine individual, environmental,
social and economic factors that may affect the quality of
life in elderly residents in a nursing home and to examine
the correlation between different variables, including, in
particular, anemia, fatigue, depressive symptoms and
sleep disorder, and the quality of life.
2. MATERIALS AND METHODS
This cross-sectional study was conducted in Gazioğlu
Nursing Home, located in the city center of Kayseri, be-
tween October 2008 and October 2009. The study en-
rolled a total of 136 nursing home residents aged 65
years and over, who had normal cognitive functions and
no psychiatric problems, severe visual disturbances
(blindness) or hearing impairment (deafness). The sub-
jects had been residents in the nursing home for at least
six months or one year. The study was approved by the
Ethics Committee of Erciyes University. Institutional
approval was given by the Provincial Directorate of Na-
tional Education. Written informed consent was obtained
from participants in the study.
2.1. Measurements
2.1.1. WHOQOL-OLD
This Module is consists of 24 Likert-type questions
and 6 subdomains. These domains are classified under
the topics “sensorial functions, autonomy, past-present-
future activities, social participation, death and dying,
intimacy”. The “Sensorial functions” domain examines
the effect of changes experienced in sight, hearing, touch,
smell and taste on quality of life; the “autonomy” domain
questions independence, respect, general control of life,
independent decision-making, and the effect of these
factors on quality of life; and the “past-present-future
activities” domain relates to the success obtained by
subjects in their lifetime and the satisfaction felt as a
result of this success, talking about the past and their
feelings and thoughts about the future. The “social par-
ticipation” domain examines their views about the use of
time and participation in important activities; the “inti-
macy” domain examines their relations with other people
and social assistance; and the “death and dying” domain
examines their thoughts about the acceptance and the
inevitability of death and the meaning of death. For each
question, the lowest possible score is 1.0 and the highest
possible score is 5.0. The validity and safety of the
WHOQOL-OLD form, which was developed by Bullin-
ger et al. [1]. In this study WHOQOL-OLD Cronbachs’s
α coefficient was 0.76.
2.1.2. GDS
For the depressive symptoms level, GDS was used.
This scale consists of 30 closed-ended questions and the
responders are asked to give “yes” or “no” answer. The
total score ranges between 0 and 30. The cut-off score is
13/14. When the score increases above the cut-off score,

V. Şenol et al. / Health 5 (2013) 212-221
214
depressive mood is increased. In this study “yes” an-
swers were scored by “0” and “no” answers were scored
by “1” for questions 1, 5, 7, 9, 15, 19, 21, 28, 29 and 30;
and for the remaining questions, “yes” answers “were
scored by “1” and “no” answers of were scored by “0”.
This scale was developed by Yesavage et al. [11].
2.1.3. FSS
Level of fatigue was measured using FSS. FSS evalu-
ates the severity of fatigue based on 9 questions. Each
question is scored between 1 (completely disagree) and 7
(completely agree). The FSS total score is the mean of 9
scores and varies between 0 and 7. The cut-off value is 4
points. Scores between 0 and 4 are considered as “with-
out fatigue” and scores between 4.1 and 7.0 are consid-
ered as “with fatigue”. Higher scores indicate increased
fatigue severity. The scale questions the effect of the fa-
tigue on the motivation, daily life activities and respon-
sibilities of the individual. FSS was developed by Krupp
et al. [12].
2.1.4. PSQI
Sleep quality was evaluated by the Pittsburgh Sleep
Quality Index (PSQI), which has consisted of 24
questions and seven components: 1) subjective quality of
sleep, 2) sleep onset latency, 3) sleep duration, 4) sleep
efficiency, 5) presence of sleep disturbances, 6) use of
hypnotic sedative medication, and 7) presence of day-
time disturbances, as an indication of daytime alertness.
Each component is scored from 0 to 3, yielding a total
PSQI score between 0 and 21. Individuals with a total
PSQI > 5 were considered to be poor sleepers. PSQI was
developed by Buysse et al. (1989) [13] and validation of
PSQI in the Turkish population was done by Agargun et
al. (1996) [14].
Anemia was evaluated using the World Health Orga-
nization’s criteria, according to which anemia is defined
as Hb < 13 g/dl and Htc < 39% in men and Hb < 12 g/dl
and Hct < 36% in women [15].
To obtain for post-prandial blood glucose, the limit
values of the reference laboratory were taken as a basis,
according to which the following values were accepted:
>70 mg/dL, low; 70 - 110 mg/dL, normal; and >110
mg/dL, high.
2.2. Statistical Analysis
Study data were evaluated using SPSS 18.0 software.
For the data, mean, standard deviation and percentages
were calculated. Independent groups were compared
using Student’s t-test, One-Way ANOVA, WHOQOL-
OLD total and subdomain scores, the power and direc-
tion of the correlation between anemia, fatigue, depres-
sion and sleep index scores were determined using
Spearman correlation analysis. p values < 0.05 were con-
sidered as statistically significant.
3. RESULTS AND DISCUSSION
The distribution of study group by socio-demographic
characteristics is given in Table 1.
Ta b l e 2 shows the mean scores for the quality of life
domains.
Table 3 shows the distribution of prevalence and the
mean scores for independent variables that may affect the
quality of life, including anemia, fatigue, depression,
sleep disorder and daytime sleepiness, by gender.
Ta bl e 4 shows the correlation between the independ-
ent variables and subdomains of the WHOQOL-OLD
Module.
Table 5 shows the correlation analysis between
WHOQOL-OLD domain scores and FSS, GDS, PSQI,
ESS, hemoglobin and glucose levels.
In this study, 78.7% of the subjects had a chronic dis-
ease. These people had lower subdomain scores of social
participation, death and dying and intimacy than healthy
peers, but the difference was not statistically significant
(p > 0.05).
4. DISCUSSION
It is known that aging leads to a potential marked de-
crease in quality of life. Therefore, aging is an important
determinant of life satisfaction. The aging-related de-
crease observed in physiologic reserves reduces toler-
ance for potential factors which may affect quality of life,
and thereby, the elderly person who is taken out of his/
her accustomed environment, may experience a deeper
effect from these factors. Housing environments, like
nursing homes, have a similar potential effect [4].
In this study, we investigated the relations between
quality of life and variables such as anemia, fatigue, de-
pressive symptoms and sleep disorder in people aged 65
years and over, residing in a nursing home. This is the
first study to examine the correlation between quality of
life and anemia.
4.1. Quality of Life and Its Affecting Factors
In our study, the WHOQOL-OLD mean score was
43.45 ± 10.30, which is lower than that found (56.02 ±
11.86) in the study performed by Eser et al. [16]. As seen
in the validity study, the intimacy domain score, which is
one of the subdomains of quality of life, showed the
highest score; this was followed by sensorial functions
and past-present-future activities. The autonomy domain
score, which was the second highest score in the validity
study, was found to be the lowest domain score in our
study (Table 2).
In our study, when determining quality of life, the
mean total score was considered as the cut-off point and,

V. Şenol et al. / Health 5 (2013) 212-221 215
Table 1. Distribution of socio-demographic characteristics (n: 136).
Socio-demographic characteristics Number %
Female 55 40.4
Gender Male 81 59.6
65 - 69 27 19.9
70 - 74 38 27.9
75 - 79 33 24.3
Age groups
80+ 38 27.9
Illiterate 88 64.7
Primary school 40 29.4 Level of education
Secondary and high school 8 5.9
Married 21 15.4
Widowed/divorced 113 83.1 Marital status
Single 2 1.5
Low (50 - 450 TL) 87 64.0
Monthly income Middle (451 - 900 TL) 49 36.0
Yes 128 94.1
Have a child No 8 5.9
Mean number of children: 3.3 ± 2.2 (min: 1, max: 10); Mean duration residence in nursing home: 3.1 ± 2.6 yr (min: 1, max: 18); Mean number of chronic dis-
eases: 4.4 ± 2.9.
Table 2. Distribution scores of WHOQOL-OLD (n: 136).
WHOQOL-OLD subdomains M ± SD* Cronbach’s α
Sensorial functions 45.49 ± 16.41
Autonomy 35.70 ± 19.96
Past-present-future activities 44.16 ± 16.31
Social participation 43.52 ± 17.10
Death and dying 43.10 ± 16.21
Intimacy 48.75 ± 17.96
Total score 43.45 ± 10.30
0.76
*M ± SD: Mean ± Standard Deviation.
accordingly, it was observed that approximately half of
the residents had a poor quality of life, with a score be-
low the mean score. Anemia, fatigue, depressive symp-
toms and sleep disorder had a significant adverse effect
on the autonomy, social participation, intimacy, death
and dying subdomain scores of the quality of life scale.
Fatigue and glucose level were variables which had a
significant effect on the total score of the quality of life
scale.
4.2. Fatigue and Its Effects on Quality of Life
In our study, the overall prevalence of fatigue was
41.2%, and frequency and grade of fatigue was signifi-
cantly (p < 0.001) higher in women compared to men
(Table 3). This percentage was slightly higher compared
to the prevalence of fatigue found in advanced age
groups included in previously conducted community-
based studies [17].
In our study, for subjects with fatigue, the total quality
of life score, and the autonomy, social participation, and
death and dying subdomain scores were significantly (p
= 0.01) lower than those observed in subjects without
fatigue (Tab le 4). Fatigue decreased autonomy, the abi-
lity to live alone and participation in daily social activi-
ties, increased concerns, anxiety and fears about death
and dying, and thereby, significantly (p < 0.001).

V. Şenol et al. / Health 5 (2013) 212-221
216
Table 3. Distribution scores of different scales according to gender (n: 136).
Gender
Male Female Total
Parameters
n % n % n % p
Hemoglobin (gr/dL)
Under cut-off point (F: <12 & M: <13 gr/dL) 39 48.1 23 41.8 62 45.6
Above cut-off point (F: ≥12 & M: ≥13 gr/dL) 42 51.9 32 58.2 74 54.4 >0.05
Mean Hb score (M ± SD)* 12.9 ± 2.0 12.0 ± 1.9 12.5 ± 2.0 0.01
Glucose (mg/dL)
Under cut-off point (<70 mg/dL) 4 4.9 1 1.8 5 3.7
Normal (70 - 110 mg/dL) 30 37.0 19 34.5 49 36.0
Above cut-off point (>110 mg/dL) 47 58.0 35 63.6 82 60.3
>0.05
Mean glucose score (M ± SD)* 125.8 ± 46.4 142.8 ± 63.3 132.7 ± 54.3 >0.05
Fatigue Severity Scale (FSS)
Under cut-off point (0 - 4 p) 59 72.8 21 38.2 81 58.8
Above cut-off point (4.1 - 7 p) 22 27.2 34 61.8 55 41.2 <0.001
Mean FSS score (M ± SD)* 3.4 ± 1.7 4.8 ± 1.9 3.9 ± 1.9 <0.001
Geriatric Depression Scale (GDS)
Under cut-off point (0 - 13 p) 35 43.2 14 25.5 49 36.0
Above cut-off point (14 - 27 p) 46 56.8 41 74.5 87 64.0 0.03
Mean GDS score (M ± SD)* 14.8 ± 4.7 16.4 ± 5.3 15.4 ± 5.0 >0.05
Pittsburg Sleep Quality Index (PSQI)
Under cut-off point (0 - 5 p) 45 55.6 16 29.1 61 44.9
Above cut-off point (6 - 17 p) 36 44.4 39 70.9 55 55.1 0.02
Mean PSQI score (M ± SD)* 5.3 ± 2.8 7.1 ± 3.4 6.0 ± 3.2 0.02
Epworth Sleepiness Scale (ESS)
Under cut-off point (0 - 9 p) 64 79.0 41 74.5 105 77.2
Above cut-off point (10 - 24 p) 17 21.0 14 25.5 31 22.8 >0.05
Mean ESS score (M ± SD)* 5.7 ± 5.5 6.3 ± 6.5 5.9 ± 5.9 >0.05
*M ± SD: Mean ± Standard Deviation.
reduced overall quality of life (Table 5). Likewise, fa-
tigue, varying from lassitude to exhaustion, impairs the
general status of the person, by leading to effects such as
physical and mental energy deficiency, reduced concen-
tration and motivation, difficulty in remembering and
voluntary isolation, and has an adverse effect on achiev-
ing, using and restoring the individual’s capacity [18].
Thus, in one study, fatigue was found to be the most
commonly defined reason for limited activities in elderly
people [19] and was reported as the most important cause
of disability, especially in women of the same age group
[20]. Therefore, it was demonstrated that there was a
negative correlation between chronic fatigue and quality
of life [21], and that physical and mental health-related
quality of life was significantly lower in subjects with
chronic fatigue compared to those without [22].
4.3. Depression and Its Effects on Quality of
Life
In our study, 2/3 of the residents were defined as hav-
ing depressive symptoms (Table 3). In studies conducted
in our country [23,24], the corresponding percentages
were detected as 13.8% - 0.4% in elderly nursing home
residents. Residing in a nursing home is different from
residing in one’s own home and increases the risk of de-
pression by 1.52 times [25].
In our study, the presence of depression significantly
(p = 0.02) reduced the WHOQOL-OLD intimacy do-
main score (Table 4). A significant inverse correlation
was found between depressive symptoms and the social
partipation and autonomy domain scores (Ta bl e 5), and
it was seen that, with the increasing severity of depres-
sion, residents showed reduced capacity to participate in

V. Şenol et al. / Health 5 (2013) 212-221 217
Table 4. The mean scores of WHOQOL-OLD according to anemia, fatigue, depression and sleep disorder (n: 136).
WHOQOL-OLD Subdomains
Sensorial
activities Autonomy Past-present- future activitiesSocial participationDeath and dying Intimacy
Total
score
Independent
variables
M ± SD M ± SD M ± SD M ± SD M ± SD M ± SD M ± SD
Anemia
Present 46.87 ± 16.46 36.29 ± 19.49 45.86 ± 14.3541.43 ± 15.56 41.73 ± 15.5945.46 ± 16.94 42.94 ± 10.00
Absent 44.34 ± 16.39 35.21 ± 20.47 42.73 ± 17.7645.27 ± 18.20 44.25 ± 16.7351.52 ± 18.44 43.89 ± 10.60
p value >0.05 >0.05 >0.05 >0.05 >0.05 0.048 >0.05
Fatigue
Present 46.42 ± 19.72 33.59 ± 24.55 46.09 ± 15.9838.50 ± 19.50 35.93 ± 18.6648.54 ± 21.21 43.00 ± 11.95
Absent 44.84 ± 13.73 37.18 ± 16.00 41.40 ± 16.5347.03 ± 14.30 48.12 ± 12.0348.90 ± 15.43 44.02 ± 7.88
p value >0.05 0.04 >0.05 0.006 <0.001 >0.05 0.01
Depression
Present 46.40 ± 16.93 38.00 ± 21.90 41.071 ± 15.9846.30 ± 15.14 41.95 ± 17.5246.19 ± 17.86 43.55 ± 8.70
Absent 43.87 ± 15.49 31.63 ± 15.33 45.90 ± 16.3341.95 ± 18.00 45.15 ± 13.5153.31 ± 17.40 43.40 ± 11.15
p value >0.05 0.04 >0.05 >0.05 >0.05 0.025 >0.05
Sleep disorder
Present 46.66 ± 18.47 35.00 ± 22.67 44.00 ± 16.9543.41 ± 20.15 40.00 ± 17.1948.91 ± 19.09 43.00 ± 11.95
Absent 44.05 ± 13.40 36.57 ± 16.17 44.36 ± 15.6343.64 ± 12.52 46.92 ± 14.1448.56 ± 16.62 44.02 ± 7.88
p value >0.05 >0.05 >0.05 >0.05 0.01 >0.05 >0.05
Daytime sleepiness
Present 50.00 ± 16.05 40.12 ± 27.65 46.77 ± 19.8841.53 ± 19.66 40.12 ± 17.8849.79 ± 20.05 44.72 ± 10.35
Absent 44.16 ± 16.35 34.40 ± 17.00 43.39 ± 15.1344.10 ± 16.32 43.98 ± 15.6748.45 ± 17.39 43.08 ± 10.30
p value >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05
Level of blood glucose concentr a tion (mg/dL)
<70 51.25 ± 17.34 41.25 ± 13.69 47.50 ± 25.6151.25 ± 5.22 42.50 ± 6.77 53.75 ± 23.63 47.91 ± 7.47
70 - 110 46.55 ± 19.13 34.82 ± 21.94 44.38 ± 18.9141.19 ± 18.91 42.09 ± 19.2544.89 ± 18.47 42.32 ± 11.69
>110 44.51 ± 14.61 35.89 ± 19.16 44.43 ± 16.3144.43 ± 16.31 43.75 ± 16.2150.76 ± 17.13 43.86 ± 9.54
p value >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05
Table 5. Correlation between WHOQOL-OLD subdomain scores and hemoglobin, glucose, fatigue, depression and sleep disorder.
Scales Biochemical parameters
WHOQOL-OLD Subdomains FSS GDS PSQI ESS Hb Glucose
Sensorial activities 0.052 0.045 0.121 0.160 −0.062 −0.049
Autonomy −0.005 0.121 0.009 −0.044 −0.015 0.167
Past-present-future activities −0.189* 0.136 −0.018 0.084 −0.020 −0.036
Social participation −0.245** −0.186* 0.003 −0.112 0.119 0.193*
Death and dying −0.340** −0.162 −0.140 −0.209** 0.113 0.156
Intimacy 0.009 −0.264** 0.030 0.046 0.052 0.182*
Total score −0.192* −0.062 0.003 −0.006 0.051 0.179*
*Correlation is significant at the 0.05 level (two-tailed); **Correlation is significant at the 0.01 level (two-tailed).

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218
societal activities and to build personal and private rela-
tions.
Depression hinders the social relations and the capa-
city to build intimacy, by leading to a loss of physical
and cognitive ability, and affects quality of life, by caus-
ing social isolation and by impairing care to physical and
mental health [1,26]. Similar to our results, in studies
conducted in our country [27] and in other countries [28]
using different scales to evaluate the quality of life, de-
pressive symptoms adversely affected the quality of life
of elderly people, especially in the physical, psychologi-
cal, social relations and environmental domains. Being
active and participating is good for elderly people. A
wide social network, including relations with family,
relatives and neighbors, is important for them. Social
relations increase health perception and the level of a
person’s well-being. In various studies perform [24,29],
it was seen that depression was significantly resolved in
elderly people who had a visitor and/or went home for
the weekend and in those who built good relations with
family members and other people living in the nursing
home; it was found that frequent visits to those in nurs-
ing homes had a positive effect on their quality of life,
more specifically in the physical and psychological do-
mains and in the domain of social relations [27,30], and
that good relations with family members improved qua-
lity of life [31]. This was caused by the fact that partici-
pation in social networks makes life easier, provides a
balance against the adverse aspects of aging and com-
pensates for the loss of important social roles. Therefore,
it contributes to a feeling of security, perception of per-
sonal worthiness and social adequacy in elderly people.
As a consequence, providing individual and social
support to allow elderly people who live in society and in
the nursing homes to build good relations with other re-
sidents, increasing the frequency of relatives/friends. The
institution management encouraging the friends and fa-
mily of residents to visit training, and motivating the
elderly person to continue his/her social activities and
hobbies all improve quality of life, by decreasing the in-
cidence of depressive symptoms.
4.4. Sleep Disorder and Its Effects on
Quality of Life
Sleep, which constitutes an important domain in
health-related quality of life, is a major human need that
takes up approximately one third of the human’s life, and
is an important indicator in physical and mental health
impairments [32]. Meeting the need for sleep and good
sleep quality are important in elderly people to maintain
and protect memory, cognitive functions, concentration,
affection, and motor functions as well as a good neuronal
and endocrine system status, and thereby, a good state of
health, and quality of life [33].
In our study, more than half of the residents had mode-
rate sleep disorder. The Prevalence of sleep disorder and
the mean PSQI score were significantly (p = 0.02) higher
in women compared to men (Tab le 3). Based on the re-
sults obtained from other studies conducted in our coun-
try, which supported our findings, it was reported that
between 61% - 77% of nursing home residents [34]. In
epidemiologic studies performed in other countries, it
was confirmed that, with an aging population, the inci-
dence of poor sleep quality, as well as specific medical
and psychological problems, was increased in elderly
people [35]. It was reported that for people aged 65 years
and over, approximately half of those who live in their
own homes, and approximately two thirds of those who
reside in long-term nursing homes had sleep disorders
[36].
In our study, poor sleep quality significantly (p = 0.01)
reduced the WHOQOL-OLD death and dying domain
score (Table 4). Therefore, residents with sleep disorders
experienced concerns, anxiety and fears about death and
dying more often. On the other hand, an indirect correla-
tion was found between the total score and death and
dying domain score in experienced the Epworth sleepi-
ness scale, and, therefore, it was noted that the more day-
time somnolence was, the more concerns, anxiety and
fears about death and dying individuals felt (Table 5).
In healthy people, chronic sleep disorders decrease
quality of life and increase mortality, by leading to fa-
tigue, depression and decreased mental functions. Eld-
erly people need good sleep quality to maintain optimum
quality of life and to protect their physical and mental
functions [37].
4.5. Anemia and Its Effects on Quality of Life
Anemia is a commonly encountered problem in popu-
lations aged 65 years and over and its incidence increases
with advanced age.
In our study, nearly half of the residents were anemic
according to WHO criteria for anemia, and the frequency
of the condition was significantly higher in men (Table
3). Approximately 1/3 in the residents of nursing homes
was reported to be anemic in studies performed in our
country [38]. Studies conducted in other countries re-
vealed a value of >50% [39]. Similar to our findings, it
was reported that the prevalence of anemia was higher in
men compared to women. While the prevalence of ane-
mia determined in this study was higher than that ob-
tained in other studies conducted in our country, it was
lower than the prevalence values found in studies per-
formed in other countries.
Anemia, which is considered as a factor that paves the
way to ill health, is currently considered as a risk factor

V. Şenol et al. / Health 5 (2013) 212-221 219
for death, which causes serious impairment of quality of
life, morbidity and decreased physical functions.
In our study, the WHOQOL-OLD intimacy subdomain
score was significantly lower for anemic elderly people
compared to those who were not (p = 0.04) (Table 4). In
the study performed by Lucca et al. [40] a close relation
was found between moderate anemia and health-related
quality of life in the elderly population.
The most important factors to affect quality of life in-
clude temporary adverse effects on cognitive functions
related to inadequate oxygenation of the brain, due to
anemia, asthenia, headache, negative health perception,
mood disorders, and physical limitation (agility) and
immobility due to falls [41]. Similarly, in our study, the
ability of residents to build private and individual rela-
tions might be adversely affected due to similar influ-
ences.
4.6. Glucose Levels and Their Effects on
Quality of Life
While the comparison of subdomain scores of glucose
levels and quality of life did not show a significant cor-
relation, correlation analysis revealed a positive correla-
tion between glucose levels and the intimacy domain
score (Table 5). It was observed that residents with a
glucose level above the normal limit (>110 mg/dL) were
better at building private and personal relations.
On the other hand, although only depressive symp-
toms were significant in anemic elderly people (p = 0.04),
fatigue, sleep disorder and daytime sleepiness were
higher. Therefore, anemia had a negative effect on qual-
ity of life, by adversely affecting other quality of life
predictors, via direct or indirect action.
5. CONCLUSION
Consequently, the mean quality of life score obtained
for nursing home residents aged 65 years and over was
43.4 ± 10.3, which is a low value. Intimacy was the sub-
domain with the highest mean score, and autonomy had
the lowest mean score. Fatigue, depression, sleep disor-
der and anemia were the main determinants to affect
quality of life. The most commonly affected domains
included autonomy, social participation, death and dying
and intimacy. Therefore, marked improvements could be
obtained in quality of life and potential life expectancy,
by striving to eradicate the depressive symptoms that
affect quality of life, accepting anemia and fatigue as a
normal physiologic response to aging, performing com-
prehensive etiological examinations in anemic elderly
people, offering elderly people the opportunity to parti-
cipate in social activities, to exercise, and to continue
their hobbies, and by providing adequate and efficient
health care.
6. ACKNOWLEDGEMENTS
We thank Proofreading Office who provided a native speaker on be-
half of Presidency of Erciyes University.
REFERENCES
[1] Bullinger, M., Power, MJ., Aaronson, N.K., Cella, D.F.
and Anderson R.T. (1996) Creating and evaluating cross-
cultural instruments, In: Spilker, B., Ed., Quality of Life
and Pharmaco Economics in Clinical Trials, Lippin-
cott-Raven, Hagerstown
[2] Barker, W.H. (1998) Prevention of disability in older
persons. In: Wallace, R.B., Ed., Maxcy-Rosenau-Last Pub-
lic Health & Preventive Medicine, 14th Edition, Appleton
& Lange, Norwalk.
[3] Lu, H. and Hu, M. (2002) Complementation on Shanghai
health care for the elderly in the 21st century. Hong Kong
Geriatrics Society, 11, 18-50.
[4] Telatar, T.G. and Özcebe, H. (2004) Increasing quality of
life of elderly. Turkish Journal of Geriatrics, 7, 162-165.
[5] Takahashi, R. and Okugawa, S. (1991) Correlation of
health status, disability and hospital life and satisfaction
with quality of life in elderly in-patients. Nippon Ronen
Igakkai Zasshi, 28, 515-519.
doi:10.3143/geriatrics.28.515
[6] Groessl, E.J, Kaplan, R.M. Rejeski, W.J., Katula, J.A.,
King, A.C., Frierson, G. and Glynn N. (2007) Health-re-
lated quality of life in older adults at risk for disability.
American Journal of Preventive Medicine, 33, 214-218.
doi:10.1016/j.amepre.2007.04.031
[7] Browne, J.P., O’Boyle, C.A., McGee, H.M., Joyce, C.R.B.,
Mcdonald, N.J. and Malley, K.O. (1994) Individual qual-
ity of life in the healthy elderly. Quality of Life Research,
3, 235-244. doi:10.1007/BF00434897
[8] Dragomirecka, E., Bartonova, J., Eisemann, M., Kalfos,
M. and Kilian, R. (2008) Demographic and psychosocial
correlates of quality of life in the elderly from a cross-
cultural perspective. Clinical Psychology & Psychother-
apy, 15, 193-204. doi:10.1002/cpp.571
[9] Low, G. and Molzahn, A.E. (2007) Predictors of quality
of life in old age: Across validation study. Research in
Nursing Health, 30, 141-50. doi:10.1002/nur.20178
[10] Robinson, J.G. and Molzahn, A.E. (2007) Sexuality and
quality of life. Journal of Gerontological Nursing, 33,
19-27.
[11] Yesavage, J.A., Brink, T.L., Rose, T.L., Lum, O., Huang,
V., Adey, M. and Leirer, V.O. (1983) Development and
validation of geriatric depression screening scale: A pre-
liminary report. Journal of Psychiatric Research, 17, 37-
49. doi:10.1016/0022-3956(82)90033-4
[12] Krupp, L.B., Alvarez, L.A., Larocca, N.G. and Scheinberg
L.C. (1998) Fatigue in multiple sclerosis. Archives of Neu-
rology, 45, 435-437.
doi:10.1001/archneur.1988.00520280085020
[13] Buysse, D.J., Reynolds, C.F., Monk, T.H., Berman, S.R.
and Kupfer, D.J. (1989) The Pittsburgh sleep quality in-
dex: A new instrument for psychiatric and research. Psy-

V. Şenol et al. / Health 5 (2013) 212-221
220
chiatry Research, 28, 193-213.
doi:10.1016/0165-1781(89)90047-4
[14] Agargun, Y.M., Kara, H. and Anlar, Ö. (1996) The reli-
ability and validity the Pittsburgh sleep quality index.
Turkish Journal of Psychiatry, 7, 107-111.
[15] World Health Organization (1968) Nutritional anemias:
Report of a WHO scientific group. WHO technical re-
ports series 405. WHO, Geneva.
[16] Eser, S., Saatli, G., Eser, E., Baydur, H. and Fidaner, C.
(2010) The reliability and validity of the Turkish version
of the World Health Organization quality of life instru-
ment-older adults module (WHOQOL-Old). Turkish Jour-
nal of Psychiatry, 21, 37-48.
[17] Cella, D., Lai, J.S., Chang, C.H., Peterman, A. and Slavin,
M. (2002) Fatigue in cancer patients compared with fa-
tigue in the general United States population. Cancer, 94,
528-538. doi:10.1002/cncr.10245
[18] Aaronson, L.S., Teel, C.S., Cassmeyer, V., Neuberger,
G.B., Pallikkathayil, L., Pierce, J., Press, A.N., Williams,
P.D. and Wingate, A. (1999) Defining and measuring fa-
tigue. Image Journal of Nursing Scholarship, 31, 45-50.
doi:10.1111/j.1547-5069.1999.tb00420.x
[19] Gill, T.M., Desai, M.M., Gahbauer, E.A., Holford, T.R.
and Williams, C.S. (2001) Restricted activity among com-
munity-living older persons: Incidence, precipitants and
health care utilization. Annals of Internal Medicine, 135,
313-321.
[20] Leveille, S.G., Fried, L.P. and Guralnik, J.M. (2002) Dis-
abling symptoms: What do older women report? Journal
of General Internal Medicine, 17, 766-773.
doi:10.1046/j.1525-1497.2002.20229.x
[21] Martin, A., Chalder, T., Rief, W. and Braehler, E. (2007)
The relationship between chronic fatigue and somatiza-
tion syndrome: A general population survey. Journal of
Psychosomatic Research, 63, 147-156.
doi:10.1016/j.jpsychores.2007.05.007
[22] Wong, W.S. and Fielding, R. (2010) Prevalence of chronic
fatigue among Chinese adults in Hong Kong: A popula-
tion-based study. Journal of Affective Disorders, 127, 248-
256. doi:10.1016/j.jad.2010.04.029
[23] Şahin, E.M. and Yalçın, M.Y. (2003) Comparing the in-
cidences of depression at the elderly living in nursing
home or at their own homes. Turkish Journal of Geriat-
rics, 6, 10-13.
[24] Topbaş, M., Yaris, F., Can, G., Kapuca, M. and Sayar, K.
(2004) The effect of socio-demographic factors and me-
dical status on depressive symptoms of the inhabitants of
nursing home and community-dwelling elders in Trab-
zon-Turkey. Clinical Psychopharmacology Bulletin, 14,
57-60.
[25] Osborn, D.P., Fletcher, A.E., Smeeth, L., Stirling, S., Bul-
pitt, C.J., Breeze, E., et al. (2003) Factors associated with
depression in a representative sample of 14,217 people
aged 75 and over in the United Kingdom: Results from
the MRC trial of assessment and management of older
people in the community. International Journal of Geri-
atric Psychiatry, 18, 623-630. doi:10.1002/gps.896
[26] Doraiswam, P.M., Khan, Z.M., Donahue, R.M., et al. (2002)
The spectrum of quality-of-life impairments in recurrent
geriatric depression. Journal of Gerontology, 57, 134-
138. doi:10.1093/gerona/57.2.M134
[27] Yazgan, Ç., Kora, K., Topcuoğlu, V. and Kuşçu, K. (2006)
Factors influencing quality of life nondemented elderly
nursing homes residents. Turkish Journal of Geriatrics, 9,
122-125.
[28] Chan, S., Jia, S., Chiu, H., Chien, W.T., Thompson, D.R.,
Hu, Y., et al. (2009) Subjective health-related quality of
life of Chinese older person with depression in Shanghai
and Hong-Kong: Relationship to clinical factors, level of
functioning and social support. International Journal of
Geriatric Psychiatry, 24, 355-362. doi:10.1002/gps.2129
[29] Sütoluk, Z., Demirhindi, H., Savaş, N. and Akbaba, M.
(2004) Prevalence and causes of depression among elders
who live in residental homes in Adana. Turkish Journal of
Geriatrics, 7, 148-151.
[30] Tseng, S.Z., Wang, R.H. and Bistodeau, J.A. (2001) Qual-
ity of life and related factors among elderly nursing home
residents in southern Taiwan. Public Health Nursing, 18,
304-311. doi:10.1046/j.1525-1446.2001.00304.x
[31] Oleson, M., Heading, C., Shadick, K.M., et al. (1994)
Quality of life in long stay institutions in England: Nurse
and resident perceptions. Journal of Advanced Nursing,
20, 23-32. doi:10.1046/j.1365-2648.1994.20010023.x
[32] Stanley, N. (2005) The physiology of sleep and impact of
ageing. European Urology Supplements, 3, 17-23.
doi:10.1016/S1569-9056(05)80003-X
[33] Yazgan, P. (2009) Sleep problem in the elderly. Turkish
Journal of Physicalmedicine and Rehabilitation, 55, 67-
68.
[34] Eser, I., Khorshid, L. and Çinar, S. (2007) Sleep quality
of older adults in nursing homes in Turkey: Enhancing
the quality of sleep improves quality of life. Journal of
Gerontological Nursing, 33, 42-49.
[35] Martin, J., Shochat, T. and AncoliaIsrael, S. (2000) As-
sessment and treatment of sleep disturbances in older
adults. Clinical Psychology Review, 20, 783-805.
doi:10.1016/S0272-7358(99)00063-X
[36] Fetveit, A. and Bjorvatn. B. (2002) Sleep disturbances
among nursing home residents. International Journal of
Geriatric Psychiatry, 17, 604-609. doi:10.1002/gps.639
[37] Topham, D.L. (2004) Sleep and rest. In: Daniels, R., Ed.,
Nursing Fundamentals Caring & Caring Decision Mak-
ing. Delmar Thomson Learning, Winter KA. & Kuiper,
Ashland, 1306-1319.
[38] Önem, Y., Terekeci, H., Küçükardali, Y., Şahan, B. and
Solmazgül, E. (2010) Albumin, hemoglobin, body mass
index, cognitive and functional performance in elderly
persons living in nursing homes. Archives of Gerontology
and Geriatrics, 50, 56-59.
doi:10.1016/j.archger.2009.01.010
[39] Robinson, B., Artz, A.S., Culleton, B., Critchlow, C.,
Sciarra, A. and Audhya, P. (2007) Prevalence of anemia
in the nursing home: Contribution of chronic kidney dis-
ease. Journal of the American Geriatrics Society, 55, 1566-
1570. doi:10.1111/j.1532-5415.2007.01389.x
[40] Lucca, U., Tettamanti, M., Mosconi, P., Apolone, G.,

V. Şenol et al. / Health 5 (2013) 212-221 221
Gandini, F., Nobili, A., et al. (2008) Association of mild
anemia with cognitive, functional mood and quality of
life outcomes in the elderly: The “Health and Anemia”
Study. PLoS One, 3, 1-8.
doi:10.1371/journal.pone.0001920
[41] Gabrilove, J. (2005) Anemia and the elderly. Clinical con-
siderations. Best Practice & Research Clinical Haema-
tology, 18, 417-422. doi:10.1016/j.beha.2005.02.004