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Aging in Europe: a cluster analysis of the elderly in 4 European countries according to their views on successful aging

Sanchez, Stéphanea,b,; Batti, Anne S.a; Armaingaud, Didierb; Denormandie, Philippeb; Dramé, Moustaphac; Hugon, Stéphaned

doi: 10.1097/HXR.0000000000000019
Original Articles

Introduction: Concepts like “healthy aging,” “successful aging,” “aging with high functional ability” or “aging well” have been used increasingly in the last few years.

Objective: The main goal of our survey was to describe the representation of pleasure and their patterns in people aged 65 and older in 4 European countries. Our second aim was to study the characteristics of each country regarding successful aging.

Methods: This cross-sectional study including >4000 seniors was based on an online survey conducted with people aged 65 and older in 4 European countries: France, Belgium, Italy, and Germany. Our sample was representative of the population aged 65 and older in each of the countries surveyed. The survey took place from August 20 to September 29, 2014.

Results: Cluster analysis led us to define 6 profiles of elderly people with regards to “living well, aging well.” The profiles ranged from “fragile and aged” to “familial hedonist” with “socially inclined” and “independent” elders falling in the middle. Groups were not evenly distributed across countries, suggesting geographic variations in the process of aging.

Discussion: “Aging well” is a complex concept, and people from different countries have varying expectations of successful aging.

Conclusion: Further studies are needed to determine how tailored interventions can best address the needs of elderly people with different views and expectations regarding successful aging.

aDepartment of Medical Information and Performance Evaluation, Troyes Hospital, Troyes

bKorian Institute for Healthy Aging, Paris

cDepartment of Research and Public Health, Reims

dCeaQ, Paris-V University, Paris, France

Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article.

Published online 21 March 2018

Corresponding author. Address: Pôle IMEP, Hôpitaux Champagne Sud, 101 Avenue Anatole France, Troyes 10000, France. Tel: +33625036892; fax: +33325494881. E-mail address: stephane.sanchez@ch-troyes.fr (S. Sanchez).

This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc-nd/4.0/

Received July 13, 2017

Accepted February 7, 2018

Concepts like “healthy aging,” “successful aging,” or “aging well” have been used increasingly in the last few years. Initially described by Rowe and Kahn1,2, the concept of “successful aging” does not have a consensual definition. However, many authors agree on the importance of maintaining high physical and cognitive functions and of maintaining social relationships3,4. Acknowledging the role of pleasure in living a good life, it seems legitimate to question the influence of aging on the notion of pleasure. The few studies focusing on pleasure in the elderly mostly measured quality of life5. Paradoxically, pleasure patterns and representations are not frequently explored in the literature. Interventions based on pleasure or positive relationships are effective strategies to increase well-being or prevent depressive symptoms6. Knowledge about pleasure representations might help to improve Public Health policies. We hypothesized that knowledge about the different patterns of pleasure could help address the needs of the elderly population. We aimed to identify the representations of pleasure in an elderly population and find patterns which depended on their cultural environment. Here we focused on the role of the country. Our survey tried to capture the mindset of elderly people and to follow their evolution: were they fitting their age? Did they think they counted for society? What role did their family have in their lives? Were they prepared to lose their independence? What did the young think about this? This survey, named “The European barometer of successful aging” was realized by the Korian Institute for Healthy Aging and the Ipsos poll institute during the second half of 2014.

Our primary objective was to find profiles of elderly people with regards to successful aging in the population aged 65 and older in 4 European countries. The second aim of our study was to describe patterns specific to each country.

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Methods

Population

Our sample included >4000 seniors representative of the population aged 65 and older in 4 European countries: France (n=1001), Belgium (n=1014), Italy (n=1009), and Germany (n=993). The survey took place from August 20 to September 29, 2014. The quota method was applied to obtain a diverse sample capturing variations that occurred in the population. For instance, we wanted to include “young” and older retired people.

The features used for quota sampling were age, sex, region. Quotas were defined according to the sociodemographic structure of the population aged 65 and older in each of the countries surveyed, based on official national statistics.

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The access panel of the Ipsos institute

The questionnaires were given through the Access Panel Online enrolled by IIS (Ipsos Interactive Services). The access panel is a diverse panel of individuals homogenously divided on the national territory and who accept to participate in market studies regularly. This panel has existed for 12 years. This panel counts more than 600,000 individuals for whom extremely precise data have been collected in addition to the data used for the defining quotas (eg, size of household, level of earnings, level of education, number of children, etc.). This method guarantees a very high level of representativity on most of the data (age, sex, socioprofessional category, agglomeration category, and region). Many quality controls were conducted during all the steps of the survey.

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Quality tests

Quality analysis was conducted at every step of the data collection and during all the online interviews with the CONFIRM-IT software. This system provides an automated control of the questionnaire, minimizing coding errors (the system prohibits multiple answers when only one is necessary), allowing random ordering of the questions (to prevent bias due to the order of the questions), to control the coherence of some questions, and allowing quota control in real time. The software is ISO 9001 certified (2008).

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Questionnaire writing process

The questionnaire was designed by the Korian Institute for Healthy Aging, a society working with gerontologists and patients to study all aspects of aging and predict the future of health care for the elderly. A sociologist helped in designing the questionnaire. The questionnaire contained 25 items related to pleasure.

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Statistical analysis

For descriptive analysis, quantitative variables were expressed as means and SDs. Qualitative variables were presented as absolute frequencies with percentages. For the principal component analysis (PCA), we have constructed the typology with question 16 being the active variable (type of pleasures and relation to them).

We have constructed a principal component analysis from questions 6 (except item “doing my makeup”), 11, 12, 22, and 23 that served as active variables. As for illustrative variables we used questions 1, 2, 3, 4, 5, 7, 10, 13, 13bis, 14, 15, 16, 20, 21, 24, 25, and sociodemographic characteristics. Variables were scaled before they were entered in the PCA. The questions used as active variables were qualitative variables. They were transformed in quantitative variables as follows:

  • Q6: Very often=5/often=3.5/sometimes=2.5/never=1.
  • Q11: Nearly everyday=5/at least once a week=4/2–3 times a month=3/once a month=2/less than once=1/never=1.
  • Q12: Nearly everyday=5/at least once a week=4/sometimes during the month=3/sometimes during the year=2/less often than the former=1/never=1.
  • Q22: I like to do it and I do it nearly as much as I want to=5/I like to do it but I do it less than I want to=4/I practically never do it because I do not like to do it=1/I never do it because I cannot do it=2.
  • Q23: Events mentioned=5/events not mentioned=1.

From that first PCA, a typology has been created by a method of hierarchical cluster analysis (HCA), using the Ward method. For the classes’ construction, consolidation iterations were realized to improve the homogeneity inside the classes. The level of statistical significance was set at 0.05. We used SPAD software to implement the PCA.

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Results

Our population consisted of 4016 respondents across 4 countries. Population characteristics are described in Table 1. A total of 802 (20.0%) respondents were aged over 80. In total, 1136 (28.3%) lived alone. In all, 1555 (28.8%) were single. Half of the respondents lived in an apartment.

Table 1

Table 1

The PCA showed 6 groups. Table 2 shows how each group differs from the panel for selected qualitative variables. Table 3 shows group specificities for quantitative variables.

Table 2

Table 2

Table 3

Table 3

The “Anxious” group (n=700; 17.4%) comprised people who did not often go on holiday (32.6%), were less prone to pleasure, felt useless, and were afraid to become a burden for their relatives (39.3% did not feel useful for their grandchildren). People from this group tended to think they could not rely on their family or on existing legislation, and had financial and health-related problems. Thinking about their future made them anxious. Anxiety made them seek information, for instance on the internet.

The “Carefree and solitary” (n=80; 19.9%) group, with elders mostly from Belgium and Germany, was characterized by people less preoccupied by their usefulness to society and less dependent than the former. In all, 35.8% had a high level of education. They accepted their age and led an active life. This group was characterized by isolation (few contact with family), but this isolation was thought of as independence. They had better health and were less preoccupied about the future.

The “Carefree and well surrounded” (n=575, 14.3%), respondents tended to be French (32.7%), in full possession of their faculties (88.5%), they enjoyed life (life was a source of pleasure for 48.8%), and actively engaged in social relationships with their family or others. This group was composed of “seniors” confortable with their bodies, well surrounded, who fully enjoyed their retirement without thinking about the future.

People from the “Farsighted and well surrounded” group (n=575; 14.3%) felt very useful for their families (40.5% felt useful for their grandchildren) and for society (94.4%), easily interacted with other people, had numerous leisure activities and often went on holiday. Italians were well represented in this group (36.5%). However, housing was often not adapted to the level of autonomy in this group. These well surrounded people often thought about their future but did not feel anxious about it because they felt prepared (for instance they could buy a new house if their house was not appropriate anymore).

The “Reclusive in suffering” group (n=422; 10.5%) was composed of people for whom it was difficult to go on holiday (35.6%), who felt rather useless (24.4%), socially isolated, with a very restricted family. This group was older and had to face many health issues. Without people to support them, they had a tendency to close themselves to the outer world and face their pain alone.

At last the “Family” (n=620; 15.4%) group had low educational achievements (64.0%), and a few health issues. People from this group were often widowed but lived with their family. Almost half of the group (45.6%) was Italian. They found it difficult to move out but were well surrounded. The central role of the family was the main trait of this group: social interactions with the family were very frequent and these seniors often relied on their family to help them face their health issues.

European profiles are presented in Figure 1. Axis 2 is related to being more or less surrounded and axis 3 is related to being more or less confident with the future and autonomy. For instance, Germans were often in the “Carefree and solitary” or “Reclusive in suffering” group. Belgians were more frequently seen in the “Carefree and solitary” group. French people were divided in 2 groups, one that enjoyed life (Carefree and well surrounded), the other appearing to have high anxiety levels (“Anxious” group). At last Italians had a very specific profile with family playing a central role. Most Italians were in the “Farsighted and well surrounded” or “Family” groups.

Figure 1

Figure 1

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Discussion

We used HCA to identify groups of elderly people according to their views on “living well, aging well” and their surroundings. Our approach enabled us to differentiate specific profiles, ranging from “fragile and aged” to “familial hedonist” with the “socially inclined” and the “independent” types falling in between. We showed geographical variations between profiles, with well surrounded Italians, French people divided between social life, pleasure and depression, Germans either isolated or independent, and the relatively independent Belgians. Our results seem consistent with data about the typology of pleasure in the elderly, especially the French survey about pleasure7. Our survey showed a link between food-related pleasure and nutrition, also consistent with the literature8. Artistic and cultural activities have a significant influence on quality of life, even though they do not usually impact health care outcomes related to chronic disease9. Others surveys about the mindset of aging people can be linked to our typology of elders10. Our results also suggest that having multiple social interactions is associated with a more positive perception of oneself and of aging. Those results are consistent with the literature about the link between depression and social interactions11,12. Finally, the results of a French survey13 suggest that health status or age is not a significant predictor of spiritual well-being, which leads us to question the relative importance of subjective and objective dimensions of aging well.

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Strengths and weaknesses

Our population consisted of a panel of individuals recruited by a poll institute in 4 European countries, and as such may not be representative of the elderly population worldwide. However, our approach was quite original. We explored the pleasure factor that plays an essential role for maintaining a good health and aging well5. Our survey showed people over 65 consider pleasure in different ways, with profiles as diverse as hedonists, anxious elderly people who seek information online, those who enjoy a few selected activities, and those whose life revolves around their family. This approach does not claim to offer a definitive typology, as the classes could vary according to the choice of questions. However, our model offers a better understanding of pleasure in people older than 65 and could serve as a basis for improving the management of health facilities. Our study does not put undue emphasis on the distinction between the elderly and the 15–64 years old with regards to pleasure, but rather suggests that there is no generational split in the representations of pleasure and that the 15–64 age class have a simplified perception of how the elderly feel about aging well.

Finally, we acknowledge that others factors play a major role in successful aging. Recently, Stenholm et al14 survey explored aging and the emergence of comorbidity in retired and active people aged 65 or older in English speaking countries. Surprisingly, people aged 65 or older who were still working declined less rapidly than those who had retired. The results of others surveys are consistent with our exploration of pleasure in showing that social participation, social support, and social capital are associated with a better health15,16. Our survey shows that pleasure in over 65 years old often stems from social interactions, which help people feel better about aging.

Further investigations are needed to explore interventions helping the elderly that suffer most to achieve a better quality of life based on their views and expectations.

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Conclusions

Successful aging is a vast concept with multiple determinants, and the study of aging well should strive to understand the state of mind of the elderly. Understanding clusters of pleasure representations could lead to tailored interventions and better health care. A public health policy should account for links between health, social relationships, pleasure, and quality of life. This article could be a starting place to integrate the patient’s mindset in health care projects for successful aging.

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Conflict of interest statement

The authors declare that they have no financial conflict of interest with regard to the content of this report.

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References

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Keywords:

Elderly; Well-being; Europe; Social representations

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