Life Satisfaction Among Persons Living With Dementia and Those Without Dementia

Hiroshi Gotanda MD, PhD; Yusuke Tsugawa MD, PhD; Haiyong Xu PhD; David B. Reuben MD

J Am Geriatr Soc. 2023;71(4):1105-1116.

Abstract and Introduction

Abstract

Background: Despite possible major adverse cognitive, physical, social, and behavioral consequences, little is known about how persons living with dementia perceive satisfaction with life, a key component of well-being. We sought to examine (i) whether persons living with dementia perceive a lower level of satisfaction compared to their peers without dementia and (ii) whether the associations between individual characteristics and life satisfaction are different between persons living with and without dementia.

Methods: Using a nationally representative sample of community-dwelling older adults aged ≥70 years in the U.S. from the Health and Retirement Study, we compared scores on the Satisfaction with Life Scale (SWLS), a self-reported 5-item scale ranging from 1 to 7 (more satisfaction), between persons with probable dementia (n = 341) and those without (n = 5530), adjusting for individual characteristics. We also tested whether the associations between the individual characteristics and SWLS differ by dementia status.

Results: Scores on SWLS did not differ between persons with probable dementia and those without when adjusting for individual characteristics including limitations in activities of daily living (ADL) (adjusted difference, −0.09; 95% CI, −0.33 to +0.15; p-value, 0.45). However, dementia status was associated with lower life satisfaction through the mediation of limitations in ADL (total effect, −0.29; bootstrapped 95% CI, −0.47 to −0.12). Most individual characteristics associated with lower life satisfaction were similar in the two groups, including younger age, more limitations in ADL, and depression. Less wealth was associated with lower satisfaction among persons without dementia but not among those with probable dementia.

Conclusions: Dementia status was only modestly associated with lower life satisfaction through the mediation of limitations in ADL among participants who were able to provide response. Future research is warranted to determine whether life satisfaction can be used as a meaningful outcome when evaluating well-being among persons living with dementia.

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Abstract and Introduction
Background
Methods
Results
Discussion
References
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Table 1. Characteristics of the study population by dementia status
Characteristics	Total (n = 5871)	With probable dementia (n = 341)	Without probable dementia (n = 5530)	p-value
Age group				<0.001
Age 70–79	3863 (63.3)	76 (19.7)	3787 (67.1)
Age 80–89	1750 (30.4)	175 (48.7)	1575 (28.8)
Age 90+	258 (6.3)	90 (31.6)	168 (4.1)
Female	3451 (57.7)	217 (64.4)	3234 (57.1)	0.003
Race/ethnicity				<0.001
Non-Hispanic white	4733 (84.4)	251 (73.4)	4482 (85.4)
Non-Hispanic black	673 (8.3)	52 (14.7)	621 (7.7)
Hispanic	465 (7.3)	38 (11.9)	427 (6.9)
Less than high school education	4750 (80.5)	114 (39.4)	1007 (17.8)	<0.001
Wealth				<0.001
Lowest quartile	851 (15.1)	80 (26.9)	771 (14.0)
Second quartile	1318 (21.4)	102 (29)	1216 (20.7)
Third quartile	1775 (29.1)	88 (24.2)	1687 (29.6)
Highest quartile	1927 (34.4)	71 (19.8)	1856 (35.7)
Covered by Medicaid	439 (7.6)	66 (22.3)	373 (6.3)	<0.001
Social network				<0.001
0	60 (0.9)	10 (2.0)	50 (0.8)
1–2	1096 (20.5)	95 (29.3)	1001 (19.7)
3–4	4715 (78.6)	236 (68.7)	4479 (79.5)
BADL limitation score				<0.001
0	5379 (89.9)	217 (56.2)	5162 (92.9)
1–3	424 (8.2)	92 (28.7)	332 (6.4)
4–6	68 (1.9)	32 (15.2)	36 (0.7)
IADL limitation score				<0.001
0	4919 (81.2)	130 (31.1)	4789 (85.7)
1–3	842 (15.4)	143 (39.3)	699 (13.2)
4–5	110 (3.4)	68 (29.6)	42 (1.1)
Severity of dementia
Mild dementia	N/A	189 (45.8)	N/A	N/A
Moderate dementia		79 (23.8)
Severe dementia		73 (30.4)
Heart disease	2038 (34.9)	133 (40.1)	1905 (34.5)	0.12
Hypertension	4175 (69.7)	247 (72.3)	3928 (69.5)	0.26
Diabetes	1530 (25.2)	104 (30.2)	1426 (24.8)	0.09
Lung disease	721 (12.4)	46 (14.3)	675 (12.2)	0.33
Arthritis	4322 (73.5)	242 (72.4)	4080 (73.6)	0.68
Stroke	549 (9.7)	68 (20.0)	481 (8.8)	<0.001
Cancer	1312 (22.3)	77 (21.2)	1235 (22.4)	0.58
Depression	1404 (24.7)	121 (37.6)	1283 (23.6)	<0.001
Had usual source of care	5006 (85.2)	266 (77.4)	4740 (85.8)	<0.001
Hospitalization within 2 years	1793 (31.2)	122 (39.1)	1671 (30.5)	0.01

Note: The numbers are No. (%) based on the Health and Retirement Study data 2012–2014. Presented proportions are weighted to be nationally representative of older adults. p-values are from chi-squared tests comparing the characteristics of participants with probable dementia and those without probable dementia. Wealth refers to the net value of total assets, including secondary residence less all debt. Social network refers to the number of affirmative responses to the four questions asking if a participant has a partner, living children, any other immediate family, or friends. BADL limitation score is the number of the following six daily activities requiring assistance based on self-report: walking, toileting, bathing, transferring, eating, and dressing. IADL limitation score is the number of the following five daily activities requiring assistance: preparing meals, shopping for groceries, making phone calls, taking medications, and managing money based on self-report. Severity of dementia was defined using BADL and IADL (see the main text and Methods S1 for detail).
Abbreviations: BADL, basic activities of daily living; IADL, instrumental activities of daily living.

Table 2. Association between individual characteristics and Satisfaction with Life Scale
Variable	Category	Adjusted SWLS (95% CI)	Adjusted difference (95% CI)	p-value
Dementia status	With probable dementia	+4.93 (+4.70 to +5.16)	−0.09 (−0.33 to +0.15)	0.45
Dementia status	Without probable dementia	+5.02 (+4.96 to +5.08)	Ref.
Age group	Age 70–79	+4.97 (+4.90 to +5.05)	−0.37 (−0.58 to −0.15)	0.001
	Age 80–89	+5.02 (+4.95 to +5.10)	−0.32 (−0.52 to −0.12)	0.002
	Age 90+	+5.34 (+5.16 to +5.53)	Ref.
Sex	Female	+5.06 (+5.00 to +5.12)	+0.11 (+0.03 to +0.19)	0.009
Sex	Male	+4.95 (+4.87 to +5.02)	Ref.
Race/ethnicity	Non-Hispanic white	+5.02 (+4.96 to +5.09)	Ref.
	Non-Hispanic black	+4.89 (+4.76 to +5.02)	−0.13 (−0.29 to +0.02)	0.08
	Hispanic	+5.01 (+4.80 to +5.22)	−0.02 (−0.24 to +0.21)	0.89
Education	Less than high school	+5.15 (+5.03 to +5.28)	+0.17 (+0.04 to +0.31)	0.01
Education	High school or more	+4.98 (+4.92 to +5.04)	Ref.
Wealth	Lowest quartile	+4.65 (+4.51 to +4.79)	Ref.
	Second quartile	+4.82 (+4.71 to +4.93)	+0.17 (+0.01 to +0.34)	0.04
	Third quartile	+5.04 (+4.95 to +5.12)	+0.39 (+0.22 to +0.56)	<0.001
	Highest quartile	+5.27 (+5.21 to +5.33)	+0.62 (+0.46 to +0.79)	<0.001
Covered by Medicaid	Yes	+5.03 (+4.87 to +5.20)	+0.02 (−0.14 to +0.19)	0.77
Covered by Medicaid	No	+5.01 (+4.96 to +5.06)	Ref.
Social network	0	+4.72 (+4.28 to +5.16)	Ref.
	1–2	+4.83 (+4.73 to +4.94)	+0.11 (−0.35 to +0.57)	0.63
	3–4	+5.06 (+5.01 to +5.12)	+0.34 (−0.09 to +0.77)	0.12
BADL limitation score	0	+5.03 (+4.97 to +5.09)	Ref.
	1–3	+4.90 (+4.72 to +5.08)	−0.13 (−0.34 to +0.07)	0.20
	4–6	+4.47 (+4.00 to +4.93)	−0.57 (−1.04 to −0.09)	0.02
Instrumental ADL limitation score	0	+5.08 (+5.02 to +5.14)	Ref.
	1–3	+4.76 (+4.62 to +4.89)	−0.32 (−0.47 to −0.17)	<0.001
	4–5	+4.57 (+4.19 to +4.96)	−0.50 (−0.90 to −0.10)	0.01
Heart disease	Yes	+4.96 (+4.87 to +5.05)	−0.08 (−0.18 to +0.02)	0.10
Heart disease	No	+5.04 (+4.98 to +5.09)	Ref.
Hypertension	Yes	+5.02 (+4.96 to +5.09)	+0.04 (−0.06 to +0.14)	0.47
Hypertension	No	+4.99 (+4.91 to +5.06)	Ref.
Diabetes	Yes	+5.00 (+4.94 to +5.07)	−0.01 (−0.10 to +0.08)	0.80
Diabetes	No	+5.01 (+4.95 to +5.08)	Ref.
Lung disease	Yes	+4.83 (+4.67 to +4.98)	−0.21 (−0.37 to −0.06)	0.009
Lung disease	No	+5.04 (+4.98 to +5.09)	Ref.
Arthritis	Yes	+4.97 (+4.91 to +5.03)	−0.16 (−0.26 to −0.05)	0.003
Arthritis	No	+5.13 (+5.04 to +5.22)	Ref.
Stroke	Yes	+4.95 (+4.76 to +5.13)	−0.07 (−0.25 to +0.11)	0.43
Stroke	No	+5.02 (+4.97 to +5.07)	Ref.
Cancer	Yes	+4.92 (+4.82 to +5.02)	−0.11 (−0.21 to −0.02)	0.02
Cancer	No	+5.04 (+4.98 to +5.09)	Ref.
Depression	Yes	+4.53 (+4.45 to +4.62)	−0.63 (−0.73 to −0.53)	<0.001
Depression	No	+5.17 (+5.11 to +5.23)	Ref.
Had usual source of care	Yes	+5.04 (+4.99 to +5.10)	+0.21 (+0.06 to +0.36)	0.006
Had usual source of care	No	+4.83 (+4.70 to +4.97)	Ref.
Had hospitalization ≤2 year	Yes	+4.90 (+4.81 to +4.98)	−0.17 (−0.27 to −0.07)	0.001
Had hospitalization ≤2 year	No	+5.06 (+5.00 to +5.13)	Ref.

Note: We fit a linear regression model with the dependent variable being SWLS (range 1–7 with 7 being the best) and independent variables being the variables in the table as well as dummy variables for the nine Census divisions (i.e., fixed effects; coefficients not shown in the table). Adjusted SWLS are predicted SWLS adjusted for covariates using the marginal standardization method.³⁸ See the main text for the definitions of BADL and IADL limitation scores.
Abbreviations: BADL, basic activities of daily living; IADL, instrumental activities of daily living; SWLS, Satisfaction with Life Scale.

Table 3. Associations between individual characteristics and Satisfaction with Life Scale by dementia status
Variable	With probable dementia (n = 341)		Without probable dementia (n = 5530)		p-value for interaction
Variable	Adjusted difference (95% CI)	p-value	Adjusted difference (95% CI)	p-value	p-value for interaction
Age group
Age 70–79	−0.40 (−0.86 to +0.06)	0.09	−0.33 (−0.56 to −0.10)	0.006	0.78
Age 80–89	−0.40 (−0.78 to −0.01)	0.04	−0.27 (−0.51 to −0.03)	0.03	0.58
Age 90+	Ref.		Ref.
Female	+0.10 (−0.25 to +0.46)	0.56	+0.11 (+0.02 to +0.19)	0.01	0.99
Race/ethnicity
Non-Hispanic white	Ref.		Ref.
Non-Hispanic black	−0.11 (−0.61 to +0.39)	0.67	−0.15 (−0.30 to +0.00)	0.05	0.87
Hispanic	−0.11 (−0.88 to +0.67)	0.78	+0.01 (−0.22 to +0.25)	0.90	0.76
<high school education	+0.16 (−0.26 to +0.59)	0.44	+0.19 (+0.04 to +0.34)	0.01	0.92
Wealth
Lowest quartile	Ref.		Ref.
Second quartile	−0.31 (−0.87 to +0.25)	0.28	+0.26 (+0.09 to +0.43)	0.003	0.06
Third quartile	−0.04 (−0.58 to +0.49)	0.87	+0.46 (+0.28 to +0.64)	<0.001	0.08
Highest quartile	+0.05 (−0.47 to +0.57)	0.85	+0.69 (+0.50 to +0.87)	<0.001	0.03
Covered by Medicaid	+0.23 (−0.32 to +0.77)	0.40	−0.06 (−0.22 to +0.10)	0.44	0.30
Social network
0	Ref.		Ref.
1–2	+0.43 (−0.90 to +1.76)	0.52	+0.05 (−0.42 to +0.51)	0.84	0.60
3–4	+0.78 (−0.47 to +2.02)	0.22	+0.27 (−0.17 to +0.72)	0.23	0.47
BADL limitation score
0	Ref.		Ref.
1–3	−0.37 (−0.98 to +0.24)	0.23	−0.09 (−0.32 to +0.14)	0.43	0.43
4–6	−0.92 (−1.71 to −0.14)	0.02	−0.51 (−1.19 to +0.16)	0.13	0.13
IADL limitation score
0	Ref.		Ref.
1–3	−0.14 (−0.45 to +0.16)	0.35	−0.32 (−0.48 to −0.16)	<0.001	0.43
4–5	−0.34 (−0.95 to +0.26)	0.26	−0.68 (−1.32 to −0.04)	0.04	0.13
Heart disease	+0.32 (−0.09 to +0.73)	0.12	−0.12 (−0.21 to −0.03)	0.01	0.04
Hypertension	+0.10 (−0.31 to +0.50)	0.63	+0.03 (−0.07 to +0.12)	0.58	0.72
Diabetes	+0.34 (+0.04 to +0.63)	0.03	−0.03 (−0.12 to +0.06)	0.48	0.02
Lung disease	+0.01 (−0.49 to +0.52)	0.96	−0.23 (−0.39 to −0.08)	0.004	0.35
Arthritis	−0.25 (−0.61 to +0.12)	0.18	−0.15 (−0.26 to −0.05)	0.004	0.63
Stroke	−0.43 (−0.75 to −0.11)	0.01	−0.01 (−0.19 to +0.16)	0.88	0.02
Cancer	−0.22 (−0.55 to +0.11)	0.19	−0.10 (−0.21 to −0.00)	0.049	0.51
Depression	−0.47 (−0.86 to −0.07)	0.02	−0.66 (−0.75 to −0.56)	<0.001	0.33
Had usual source of care	+0.06 (−0.41 to +0.53)	0.79	+0.21 (+0.05 to +0.37)	0.01	0.56
Had hospitalization ≤2 year	−0.33 (−0.74 to +0.09)	0.12	−0.16 (−0.25 to −0.07)	0.001	0.42

Note: We fit linear regression models similar to the main analysis for each of the dementia and non-dementia groups separately. We then fit a linear regression model with interaction terms between dementia status and all other variables using all the study sample (both dementia and non-dementia groups) and present p-values for the interaction terms. See the main text for the definitions of BADL and IADL limitation scores.
Abbreviations: BADL, basic activities of daily living. IADL, instrumental activities of daily living.

Table 4. Association between dementia severity and Satisfaction with Life Scale
Variable	Category	Adjusted SWLS (95% CI)	Adjusted difference (95% CI)	p-value
Dementia status	No dementia	5.04 (4.99–5.10)	Ref.
	Mild	4.88 (4.61–5.16)	−0.16 (−0.43 to +0.12)	0.26
	Moderate	4.63 (4.21–5.05)	−0.41 (−0.83 to +0.01)	0.06
	Severe	4.36 (3.95–4.78)	−0.68 (−1.12 to −0.24)	0.003

Note: We fit a linear regression model similar to the main analysis but the main exposure variable being a categorical variable for dementia severity (no dementia, mild, moderate, or severe dementia). We did not include basic activities of daily living (BADL) and instrumental activities of daily living (IADL) limitation scores as covariates. See the main text for more details. Results for other exposure variables are not reported for brevity.
Abbreviation: SWLS, Satisfaction with Life Scale.

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Life Satisfaction Among Persons Living With Dementia and Those Without Dementia

Abstract and Introduction

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