Quality of Life Research

, Volume 22, Issue 8, pp 2051–2061 | Cite as

Explaining quality of life of older people in the Netherlands using a multidimensional assessment of frailty

  • Robbert J. J. Gobbens
  • Katrien G. Luijkx
  • Marcel A. L. M. van Assen



Although frailty was originally a medical concept, nowadays more and more researchers are convinced of its multidimensional nature, including a psychological and social domain of frailty as well as a physical domain. The objective of this study was to test the hypothesis that the prediction of quality of life by physical frailty components is improved by adding psychological and social frailty components.


This cross-sectional study was carried out with a sample of Dutch citizens. A total of 1,031 people aged 65 years and older completed a Web-based questionnaire containing the Tilburg Frailty Indicator for measuring physical, psychological, and social frailty, and the WHOQOL-BREF for measuring four quality of life domains (physical health, psychological, social relations, environmental).


The findings show that the prediction of all quality of life domains by eight physical components of frailty was improved after adding four psychological and three social frailty components. The psychological frailty component ‘feeling down’ significantly improved the prediction of all four quality of life domains, after controlling for the effects of background characteristics and all other frailty components.


This study emphasizes the importance of a multidimensional assessment of frailty in the prediction of quality of life in older people.


Frailty Older people Quality of life Tilburg Frailty Indicator Nursing 



Authors would like to thank René Schalk for collecting and making available the data.

Conflict of interest

None declared.


  1. 1.
    Boyd, C. M., Xue, Q. L., Simpson, C. F., Guralnik, J. M., & Fried, L. P. (2005). Frailty, hospitalization, and progression of disability in a cohort of disabled older women. The American Journal of Medicine, 118(11), 1225–1231.PubMedCrossRefGoogle Scholar
  2. 2.
    Fried, L. P., Tangen, C. M., Walston, J., et al. (2001). Frailty in older adults: Evidence for a phenotype. Journal of Gerontology Medical Sciences, 56(3), M146–M156.CrossRefGoogle Scholar
  3. 3.
    Ravaglia, G., Forti, P., Lucicesare, A., Pisacane, N., Rietti, E., & Patterson, C. (2008). Development of an easy prognostic score for frailty outcomes in the aged. Age and Ageing, 37(2), 161–166.PubMedCrossRefGoogle Scholar
  4. 4.
    Jones, D. M., Song, X., & Rockwood, K. (2004). Operationalizing a frailty index from a standardized comprehensive geriatric assessment. Journal of the American Geriatrics Society, 52(11), 1929–1933.PubMedCrossRefGoogle Scholar
  5. 5.
    Rockwood, K., Song, X., MacKnight, C., et al. (2005). A global clinical measure of fitness and frailty in elderly people. Canadian Medical Association Journal, 173(5), 489–495.PubMedCrossRefGoogle Scholar
  6. 6.
    Song, X., Mitnitski, A., & Rockwood, K. (2010). Prevalence and 10-year outcomes of frailty in older adults in relation to deficit accumulation. Journal of the American Geriatrics Society, 58(4), 681–687.PubMedCrossRefGoogle Scholar
  7. 7.
    Chang, Y. W., Chen, W. L., Lin, F. G., et al. (2012). Frailty and its impact on health-related quality of life: A cross-sectional study on elder community-dwelling preventive health service users. PLoS ONE,. doi: 10.1371/journal.pone.0038079.Google Scholar
  8. 8.
    Bilotta, C., Bowling, A., Case, A., et al. (2010). Dimensions and correlates of quality of life according to frailty status: a cross-sectional study on community-dwelling older adults referred to an outpatient geriatric service in Italy. Health and Quality of Life Outcomes,. doi: 10.1186/1477-7525-8-56.PubMedGoogle Scholar
  9. 9.
    Masel, M. C., Ostir, G. V., & Ottenbacher, K. J. (2010). Frailty, mortality, and health-related quality of life in older Mexican Americans. Journal of the American Geriatrics Society, 58(11), 2149–2153.PubMedCrossRefGoogle Scholar
  10. 10.
    Levers, M. J., Estabrooks, C. A., & Ross Kerr, J. C. (2006). Factors contributing to frailty: Literature review. Journal of Advanced Nursing, 56(3), 282–291.PubMedCrossRefGoogle Scholar
  11. 11.
    Markle-Reid, M., & Browne, G. (2003). Conceptualizations of frailty in relation to older adults. Journal of Advanced Nursing, 44(1), 58–68.PubMedCrossRefGoogle Scholar
  12. 12.
    Gobbens, R. J., Luijkx, K. G., Wijnen-Sponselee, M. T., & Schols, J. M. (2010). Toward a conceptual definition of frail community dwelling older people. Nursing Outlook, 58(2), 76–86.PubMedCrossRefGoogle Scholar
  13. 13.
    Hogan, D. B., MacKnight, C., & Bergman, H. (2003). Models, definitions, and criteria of frailty. Aging Clinical and Experimental Research, 15(3 Suppl), 1–29.PubMedGoogle Scholar
  14. 14.
    Gobbens, R. J., Luijkx, K. G., Wijnen-Sponselee, M. T., & Schols, J. M. (2010). Towards an integral conceptual model of frailty. The Journal of Nutrition, Health & Aging, 14(3), 175–181.CrossRefGoogle Scholar
  15. 15.
    The WHOQOL Group. (1995). The World Health Organization Quality of Life assessment (WHOQOL): Position paper from the World Health Organization. Social Science & Medicine, 41(10), 1403–1409.Google Scholar
  16. 16.
    Lee, T. W., Ko, I. S., & Lee, K. J. (2006). Health promotion behaviors and quality of life among community-dwelling elderly in Korea: A cross-sectional survey. International Journal of Nursing Studies, 43(3), 293–300.PubMedCrossRefGoogle Scholar
  17. 17.
    Paskulin, L., Vianna, L., & Molzahn, A. E. (2009). Factors associated with quality of life of Brazilian older adults. International Nursing Review, 56(1), 109–115.PubMedCrossRefGoogle Scholar
  18. 18.
    Lubetkin, E. I., Jia, H., Franks, P., & Gold, M. R. (2005). Relationship among sociodemographic factors, clinical conditions, and health-related quality of life: Examining the EQ-5D in the U.S. general population. Quality of Life Research, 14(10), 2187–2196.PubMedCrossRefGoogle Scholar
  19. 19.
    Raphael, D., Brown, I., Renwick, R., Cava, M., Weir, N., & Heathcote, K. (1997). Measuring the quality of life of older persons: A model with implications for community and public health nursing. International Journal of Nursing Studies, 34(3), 231–239.PubMedCrossRefGoogle Scholar
  20. 20.
    Hilleras, P. K., Jorm, A. F., Herlitz, A., & Winblad, B. (2001). Life satisfaction among the very old: A survey on a cognitively intact sample aged 90 years or above. The International Journal of Aging and Human Development, 52(1), 71–90.CrossRefGoogle Scholar
  21. 21.
    Netuveli, G., & Blane, D. (2008). Quality of life in older ages. British Medical Bulletin, 85, 113–126.PubMedCrossRefGoogle Scholar
  22. 22.
    Hunger, M., Thorand, B., Schunk, M., et al. (2011). Multimorbidity and health-related quality of life in the older population: results from the German KORA-age study. Health and Quality of Life Outcomes,. doi: 10.1186/1477-7525-9-53.PubMedGoogle Scholar
  23. 23.
    Rijken, M., van Kerkhof, M., Dekker, J., & Schellevis, F. G. (2005). Comorbidity of chronic diseases: Effects of disease pairs on physical and mental functioning. Quality of Life Research, 14(1), 45–55.PubMedCrossRefGoogle Scholar
  24. 24.
    Fortin, M., Bravo, G., Hudon, C., et al. (2006). Relationship between multimorbidity and health-related quality of life of patients in primary care. Quality of Life Research, 15(1), 83–91.PubMedCrossRefGoogle Scholar
  25. 25.
    Gobbens, R. J., van Assen, M. A., Luijkx, K. G., Wijnen-Sponselee, M. T., & Schols, J. M. (2010). The Tilburg Frailty Indicator: Psychometric properties. Journal of the American Medical Directors Association, 11(5), 344–355.PubMedCrossRefGoogle Scholar
  26. 26.
    Gobbens, R. J., van Assen, M. A., Luijkx, K. G., & Schols, J. M. (2012). The predictive validity of the Tilburg Frailty Indicator: Disability, health care utilization, and quality of life in a population at risk. The Gerontologist, 52(5), 619–631.PubMedCrossRefGoogle Scholar
  27. 27.
    Lin, C. C., Li, C. I., Chang, C. K., et al. (2011). Reduced health-related quality of life in elders with frailty: A cross-sectional study of community-dwelling elders in Taiwan. PLoS ONE,. doi: 10.1371/journal.pone.0021841.Google Scholar
  28. 28.
    Ware, J. E, Jr, & Sherbourne, C. D. (1992). The MOS 36-item short-form health survey (SF-36). Conceptual framework and item selection. Medical Care, 30(6), 473–483.PubMedCrossRefGoogle Scholar
  29. 29.
    Pilotto, A., Rengo, F., Marchionni, N., et al. Comparing the prognostic accuracy for all-cause mortality of frailty instruments: A multicentre 1-year follow-up in hospitalized older patients. PLoS One, doi: 10.1371/journal.pone.0029090.
  30. 30.
    Andrew, M. K., Mitnitski, A. B., & Rockwood, K. (2008). Social vulnerability, frailty and mortality in elderly people. PLoS ONE,. doi: 10.1371/journal.pone.0002232.PubMedGoogle Scholar
  31. 31.
    Treurniet, H. F., Hoeymans, N., Gijsen, R., Poos, M. J., van Oers, J. A., & Thien, W. M. (2005). Health status and the challenges for prevention in the Netherlands. Public Health, 119(3), 159–166.PubMedCrossRefGoogle Scholar
  32. 32.
    Central Committee on Research inv. Human Subjects. (2010). Does your study have to be reviewed? (Home > For investigators > Review step plan RC > WMO) Accessed June 15, 2010.
  33. 33.
    Metzelthin, S. F., Daniels, R., van Rossum, E., de Witte, L., van den Heuvel, W. J., & Kempen, G. I. (2010). The psychometric properties of three self-report screening instruments for identifying frail older people in the community. BMC Public Health,. doi: 10.1186/1471-2458-10-176.Google Scholar
  34. 34.
    WHOQOL Group. (1998). Development of the World Health Organization WHOQOL-BREF quality of life assessment. Psychological Medicine, 28(3), 551–558.CrossRefGoogle Scholar
  35. 35.
    Skevington, S. M., Lotfy, M., & O’Connell, K. A. (2004). The World Health Organization’s WHOQOL-BREF quality of life assessment: Psychometric properties and results of the international field trial. A report from the WHOQOL group. Quality of Life Research, 13(2), 299–310.PubMedCrossRefGoogle Scholar
  36. 36.
    Kalfoss, M. H., Low, G., & Molzahn, A. E. (2008). The suitability of the WHOQOL-BREF for Canadian and Norwegian older adults. European Journal of Ageing, 5(1), 77–89.CrossRefGoogle Scholar
  37. 37.
    Hawthorne, G., Herrman, H., & Murphy, B. (2006). Interpreting the WHOQOL-BREF: Preliminary population norms and effect sizes. Social Indicators Research, 77, 37–59.CrossRefGoogle Scholar
  38. 38.
    Cohen, J. (1988). Statistical power analysis for the behavioral sciences (2nd ed.). Hillsdale: Lawrence Erlbaum Assoc Inc.Google Scholar
  39. 39.
    Bowling, A. (2009). The psychometric properties of the older people’s quality of life Questionnaire, compared with the CASP-19 and the WHOQOL-OLD. Current Gerontology and Geriatrics Research,. doi: 10.1155/2009/298950.PubMedGoogle Scholar
  40. 40.
    Puts, M. T., Lips, P., & Deeg, D. J. (2005). Static and dynamic measures of frailty predicted decline in performance-based and self-reported physical functioning. Journal of Clinical Epidemiology, 58(11), 1188–1198.PubMedCrossRefGoogle Scholar
  41. 41.
    Bergman, H., Béland, F., Karunananthan, S., Hummel, S., Hogan, D., & Wolfson, C. (2004). English translation of article published in ‘Gerontologie et société’. Dévelopment d’un cadre de travail pour compendre et étudier la fragilité. Gérontologie et société, 109, 15–29.CrossRefGoogle Scholar
  42. 42.
    Fillit, H., & Butler, R. N. (2009). The frailty identity crisis. Journal of the American Geriatrics Society, 57(2), 348–352.PubMedCrossRefGoogle Scholar
  43. 43.
    Ten Doesschate, M. C., Koeter, M. W., Bockting, C. L., & Schene, A. H. (2010). Health related quality of life in recurrent depression: A comparison with a general population sample. Journal of Affective Disorders, 120(1–3), 126–132.PubMedCrossRefGoogle Scholar
  44. 44.
    Penninx, B. W., Deeg, D. J., van Eijk, J. T., Beekman, A. T., & Guralnik, J. M. (2000). Changes in depression and physical decline in older adults: A longitudinal perspective. Journal of Affective Disorders, 61(1–2), 1–12.PubMedCrossRefGoogle Scholar
  45. 45.
    Puts, M. T., Shekary, N., Widdershoven, G., Heldens, J., Lips, P., & Deeg, D. J. (2007). What does quality of life mean to older frail and non-frail community-dwelling adults in the Netherlands? Quality of Life Research, 16(2), 263–277.PubMedCrossRefGoogle Scholar
  46. 46.
    Gabriel, Z., & Bowling, A. (2004). Quality of life from the perspectives of older people. Ageing & Society, 24(5), 675–691.CrossRefGoogle Scholar
  47. 47.
    Nicholson, C., Meyer, J., Flatley, M., & Holman, C. (2012). The experience of living at home with frailty in old age: A psychosocial qualitative study. International Journal of Nursing Studies,. doi: 10.1016/j.ijnurstu.2012.01.006.PubMedGoogle Scholar
  48. 48.
    Bowling, A., Seetai, S., Morris, R., & Ebrahim, S. (2007). Quality of life among older people with poor functioning. The influence of perceived control over life. Age and Ageing, 36(3), 310–315.PubMedCrossRefGoogle Scholar
  49. 49.
    Low, G., & Molzahn, A. E. (2007). Predictors of quality of life in old age: A cross- validation study. Research in Nursing & Health, 30(2), 141–150.CrossRefGoogle Scholar
  50. 50.
    Holmes, S. (2009). Methodological and ethical considerations in designing an Internet study of quality of life: A discussion paper. International Journal of Nursing Studies, 46(3), 394–405.PubMedCrossRefGoogle Scholar
  51. 51.
    Statline. Bevolking: geslacht, leeftijd en burgerlijke staat, 1 januari. Accessed November 14, 2012.
  52. 52.
    Statistics Netherlands. Population pyramid [fact sheet]. Accessed November 13, 2012.
  53. 53.
    Gobbens, R. J., & van Assen, M. A. (2012). Frailty and its prediction of disability and health care utilization: The added value of interviews and physical measures following a self-report questionnaire. Archives of Gerontology and Geriatrics, 55(2), 369–379.PubMedCrossRefGoogle Scholar
  54. 54.
    Van Campen, C. (2011). Frail older persons in the Netherlands. The Hague: The Netherlands Institute for Social Research.Google Scholar
  55. 55.
    Pialoux, T., Goyard, J., & Lesourd, B. (2012). Screening tools for frailty in primary health care: A systematic review. Geriatrics and Gerontology International, 12(2), 189–197.PubMedCrossRefGoogle Scholar
  56. 56.
    Fall, M., Walters, S., Read, S., et al. (1997). An evaluation of a nurse-led ear care service in primary care: Benefits and costs. British Journal of General Practice, 47(424), 699–703.PubMedGoogle Scholar
  57. 57.
    Gallagher, M., Huddart, T., & Henderson, B. (1998). Telephone triage of acute illness by a practice nurse in general practice: Outcomes of care. British Journal of General Practice, 48(429), 1141–1145.PubMedGoogle Scholar

Copyright information

© Springer Science+Business Media Dordrecht 2012

Authors and Affiliations

  • Robbert J. J. Gobbens
    • 1
    • 2
  • Katrien G. Luijkx
    • 2
  • Marcel A. L. M. van Assen
    • 3
  1. 1.Rotterdam University of Applied SciencesRotterdamThe Netherlands
  2. 2.Department of Tranzo, Scientific Center for Care and WelfareTilburg UniversityTilburgThe Netherlands
  3. 3.Department of Methodology and Statistics, Tilburg School of Social and Behavioral SciencesTilburg UniversityTilburgThe Netherlands

Personalised recommendations