Archives of Gerontology and Geriatrics
30 (2000) 173 – 184
www.elsevier.com/locate/archger

Exploration of subjective well-being and
dependence in daily activities at the beginning
of the geriatric rehabilitation process: a
challenge to traditional goal-setting and
evaluation procedures?
Carita Nygren a,*, Susanne Iwarsson a, Ove Dehlin b
a

Di6ision of Occupational Therapy, Department of Clinical Neuroscience, PO Box 157,
S-221 00 Lund, Sweden
b
Department of Community Health Sciences, Lund Uni6ersity, Lund, Sweden

Received 16 December 1999; received in revised form 8 February 2000; accepted 10 February 2000

Abstract
The objectives of this study were to describe a population of elderly patients at the
beginning of their rehabilitation period as regards subjective well-being and dependence in
activities of daily living (ADL). In a Swedish rural county 244 patients aged 65 + who had
begun rehabilitation within the last month were targeted. One part of the self-administered
Goteborg Quality of Life Instrument and a revised version of the ADL Staircase were used.
¨
No correlation was found between subjective well-being and ADL dependence. However,
signiﬁcant correlations between ADL dependence and separate subjective well-being items
were found in three out of 17, i.e. the items ‘energy’, ‘leisure’, and ‘sense of signiﬁcance and
appreciation outside home’. Overall subjective well-being did not show any gender differences, but signiﬁcant gender differences due to the distribution of scores was shown; females
scored the items ‘health’, ‘sleeping’, and ‘economy’ as bad to a larger extent than males.
Males were signiﬁcantly more dependent than females in three out of nine ADL: ‘going to
the toilet’, ‘dressing’, and ‘cooking’. Additional knowledge of subjective well-being and ADL
dependence at the beginning of the rehabilitation process challenges the traditional goal-setting and evaluation procedures of geriatric rehabilitation services. © 2000 Elsevier Science
Ireland Ltd. All rights reserved.

* Corresponding author. Tel.: +46-46-2221940; fax: + 46-46-2221959.
0167-4943/00/$ - see front matter © 2000 Elsevier Science Ireland Ltd. All rights reserved.
PII: S 0 1 6 7 - 4 9 4 3 ( 0 0 ) 0 0 0 5 5 - 8

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Keywords: Activities of daily living (ADL); Quality of life; Geriatrics; Rehabilitation; Gender

1. Introduction
Rehabilitation is an individualised treatment process aiming at reducing the
effects of functional consequences of disease and injury and achieving greater
independence and social reintegration (McGrath and Davies, 1992; Weber et al.,
1995). In modelling rehabilitation processes the ICIDH (WHO, 1999) has been
widely employed (Whiteneck, 1994; Weber et al., 1995; Hoenig et al., 1997).
Traditionally the rehabilitation process has concentrated on the reduction of
impairments, with a tendency to focus on body function, but during recent years
there has been a shift towards a more activity and participation (WHO, 1999)
oriented approach (Jette, 1995; Weber et al., 1995; Glass, 1998).
In current geriatric rehabilitation practice the target is the patient’s ability to
continue to live a normal life as long as possible. The ability to perform activities
of daily living (ADL) is affected by chronic illnesses and the weakening of functions
due to the normal ageing process (Faden and German, 1994; Moseley, 1994; Era
and Rantanen, 1998; Laukkanen et al., 1998). Consequently, measures of actual
performance in ADL do not only correspond to the activity and participation
approach but are also gaining increasing importance in the development and
evaluation of geriatric care (Kurlowicz, 1993; Glass, 1998).
During the last few years there has been a growing consensus that Quality of Life
is an important indicator of geriatric rehabilitation outcome (King, 1996). The
concept of Quality of Life includes objective dimensions, e.g. diagnosis, housing,
and economy, as well as subjective dimensions, e.g. the values and preferences the
patients have in life (Gill and Feinstein, 1994) and subjective well-being (Tibblin et
al., 1990). Subjective Quality of Life has been used in the evaluation of diagnosisspeciﬁc treatment (Wyller et al., 1997; Ronning and Guldvog, 1998), but our
¨
knowledge of how geriatric patients’ subjective Quality of Life changes through a
rehabilitation process is still weak.
As indicated by the ICIDH conceptual framework, there are multifaceted relationships between the different concepts, e.g. between activity and participation
(WHO, 1999). Still, more research is needed in order to explore how the concept of
Quality of Life is related to activity and participation, but one of the few studies
available (Iwarsson and Isacsson, 1997a) reported signiﬁcant correlations between
ADL dependence and subjective well-being of old people in a Swedish sample. In
addition, their results indicated gender differences, as did the results of Helset
(1993), who stated that females tended to report lower subjective Quality of Life
even though they carried out their daily activities to a larger extent than males.
In current research, much attention is concentrated on the outcome of geriatric
rehabilitation, while less interest has been invested in how ability to perform ADL
and Quality of Life vary through the process. Even if baseline information usually
is presented in outcome studies, to our knowledge no information on the relation-

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175

ships between ADL and Quality of Life at the beginning of the rehabilitation
process is available. Such knowledge is crucial for patient centered goal-setting and
would be valuable for analyses over time, ultimately providing us with information
useful for the planning and evaluation of more efﬁcient rehabilitation programmes.
The main objectives of this study were to describe a population of elderly
patients at the beginning of their rehabilitation period as regards subjective Quality
of Life, i.e. subjective well-being, and dependence in ADL, exploring interrelationships among the underlying variables. An additional objective was to investigate
gender differences for the variables in focus.

2. Subjects and methods

2.1. Study district
In 1992 a major reform concerning the organisation of geriatric health care took
effect in Sweden. Its main purpose was to transfer the basic responsibilities for
geriatric health care services including rehabilitation from the county councils to
the municipalities. In the annual follow-up of the reform in 1994, the Swedish
Board of Health and Welfare saw major obstacles in developing efﬁcient and
high-quality geriatric rehabilitation. In order to improve the quality of geriatric
rehabilitation, the Swedish government in 1995 assigned special grants to local
geriatric rehabilitation projects. This study was accomplished within the frame of
the evaluation of the local geriatric rehabilitation projects in the southern Swedish
County of Kristianstad (Iwarsson et al., 1999). The total population of the county
was 180 000 inhabitants. It consisted of mainly rural areas with thirteen municipalities and four towns with one hospital in each. All four hospitals provided for
specialised geriatric rehabilitation in their geriatric clinics, with both in- and outpatients. In addition, in all the 13 municipalities, local rehabilitation teams provided geriatric rehabilitation, either in day-care facilities or in their own homes. In
the local teams occupational therapists and physiotherapists had the main responsibility for the rehabilitation process, with assistance from nursing staff. Medical
consultation was available from local health care centres.

2.2. Sampling procedure
Patients treated in any of the above forms of rehabilitation in the county were
included, aiming at catching a genuine geriatric rehabilitation sample, representing
the actual mixed caseload found through the chain of care (Nygren et al.,
submitted). The target population comprised of all patients aged 65 years or older
who had been referred within the last month to any of the 50 local physiotherapists
or occupational therapists who were strategically recruited as data collectors for
this study. The patients were to have communicative skills in the Swedish language
and cognitive function adequate enough to participate in study procedures, and to
have no known alcohol or drug abuses (Nygren et al., submitted). The therapists

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were asked to recruit all the patients from their current records who at the time of
the study met the inclusion criteria. In all 279 patients were identiﬁed and assessed
within one month from admission to rehabilitation. Due to 35 incomplete assessments, the ﬁnal sample consisted of N= 244.

2.3. Instruments
For assessment of subjective well-being the self-administered Goteborg Quality of
¨
Life Instrument (Goteborg QoL) (Tibblin et al., 1990) was used. This instrument
¨
consists of two parts: one assessing subjective well-being, the other different
symptoms. In this study only the well-being scale was used. The original version of
the scale consisted of 15 items pertaining to social, physical, and mental well-being.
In this study a later version including 18 items was used (Tibblin et al., 1990;
Iwarsson and Isacsson, 1997a), but since all respondents in this study were retired
from work, the item ‘work’ was excluded. The patients rated each item on a
seven-step ordinal scale; from ‘very bad’ (= 1) to ‘excellent, couldn’t be better’
(= 7). The maximum total score of the 17 items used was 119, indicating excellent
subjective well-being. According to Iwarsson and Isacsson (1997a), the internal
consistency of the scale allows for the use of a summed score. In this study as well,
the internal consistency of the summed subjective well-being scale of the Goteborg
¨
Quality of Life Instrument was evaluated with Cronbach alpha (Cronbach, 1951).
For group comparison alpha coefﬁcients of 0.50–0.70 are considered adequate,
while for reliable individual comparisons a score of 0.90 is needed (Ware, 1984;
Birren et al., 1991). In the current study, the internal consistency of the summed
subjective well-being scale was 0.84.
Dependence in daily activities was assessed with the ADL Staircase (Sonn and
,
Hulter-Asberg, 1991), revised version (Iwarsson and Isacsson, 1997b). The ADL
Staircase is a further development of Katz’s ADL Index (Katz et al., 1963) for
assessment of dependence/independence in personal daily activities (P-ADL) and
instrumental daily activities (I-ADL). The instrument consists of ﬁve activities in
P-ADL: feeding, transfer, going to the toilet, dressing, and bathing, combined with
four I-ADL activities: cooking, transportation, shopping, and cleaning, in the
hierarchical order enumerated. In congruence with previous research in rural areas
(Iwarsson and Isacsson, 1997b; Iwarsson, 1998) two alternative items of transportation were eligible. If the patient previously had used public transportation the
,
original item was used (Sonn and Hulter-Asberg, 1991), but if they had used their
own car, the item revised by Iwarsson and Isacsson (1997b) was used. The results
were summarised into hierarchical ADL grades from 0 (independent in all activities) to 9 (dependent in all activities). Persons who could not be classiﬁed according
to the cumulative scale, i.e. those who demonstrated a divergent pattern of
,
dependence, were classiﬁed as ‘others’ (Sonn and Hulter-Asberg, 1991). In order to
maximise the discriminative power of the data and to be able to include respondents classiﬁed as ‘others’, ADL ranks were calculated (Iwarsson et al., 1998). In
this study the largest proportion of dependence was demonstrated in transportation, followed by cleaning, shopping and cooking. Consequently, the ADL grades

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177

were calculated in this hierarchical order (Iwarsson and Isacsson, 1997b). Internal
reliability and validity of the ADL Staircase was evaluated by Guttman’s coefﬁcient
of reproducibility, COR. (Guttman, 1950) and Menzel’s scaling coefﬁcient, COS.
(Menzel, 1953). The lowest acceptable limits are 0.90 for COR and 0.60 for COS.
In this study the COR=0.97 and the COS= 0.88.

2.4. Accomplishment
The 50 local physiotherapists and occupational therapists served as data collectors in the respondent’s home or at the rehabilitation facilities during a period of
eight weeks. The Goteborg QoL Instrument and the ADL Staircase revised version
¨
were administered in accordance with the instructions for each instrument. In
addition, descriptive data were collected. As far as possible the data collectors
interviewed patients not known to them. In order to optimise reliability and data
quality, the authors arranged several data collector seminars, discussing problems
and experiences from using the instruments.

2.5. Statistical methods
Spearman’s Rank correlation between ADL dependence and summed subjective
well-being was calculated on the 78% of the subjects who had answered all the
questions in the subjective well-being scale (Tibblin et al., 1990). Rank correlations
between the separate items of the subjective well-being scale and ADL dependence
were calculated on the number of subjects who had answered each of the separate
items.
In order to investigate gender differences in subjective well-being, ﬁrst the
subjective well-being scores were trichotomised in the following way: ‘bad’ (=1–3),
‘neither good nor bad’ ( =4) and ‘good/excellent’ (= 5–7). Next, in order to
control for age, gender differences were computed with the Mantel–Haensel test
(Altman, 1994). Gender differences in ADL-dependence were computed with the
chi-squared test.
Results with P B0.05 were considered statistically signiﬁcant.

3. Results

3.1. Description of the study sample
Ninety-one per cent of the patients had their rehabilitation in day-care facilities
or at home, while 9% were admitted to hospital. Of the patients treated in day-care
facilities or at home, 44% lived in sheltered housing facilities while 55% lived in
ordinary housing. The mean age of the total sample was 78 years, range 65–95
years. For females the mean age was 79 years, range 65–95 years, and for males the
mean age was 77 years, range 65–92 years. The majority of the patients were
females and lived alone (Table 1).

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3.2. Subjecti6e well-being and ADL dependence
The subjects who had completed the subjective well-being scale (78%) rated their
general well-being as rather high, Md= 86, total score range 43–116. An analysis
of the separate items showed Md= 7 for the item ‘sense of signiﬁcance and
appreciation at home’. For none of the 17 items was the median score lower than
four (Table 2).
The result of the assessment of ADL dependence showed that 3% of the patients
were independent in ADL, while 65% were dependent in both P-ADL and I-ADL.
The remaining 32% were dependent only in I-ADL.

3.3. Correlations between subjecti6e well-being and ADL dependence
No signiﬁcant correlation was found between the summed subjective well-being
scale and ADL dependence, nor was any signiﬁcant correlation found when
analysing females and males separately. However, signiﬁcant correlations between
ADL dependence and separate subjective well-being items were found in three out
of 17, namely between ADL dependence and one item from the mental well-being
scale, ‘energy’ (P =0.005), and between ADL dependence and two items from the
social well-being scale, ‘leisure’ (P =0.040) and ‘sense of signiﬁcance and appreciation outside home’ (P =0.023). No signiﬁcant correlation was found between any
of the items of the physical well-being scale and ADL dependence.

3.4. Gender differences
Summed subjective well-being (Table 2) did not differ between females (Md= 85)
and males (Md =87). However, further analyses revealed signiﬁcant gender differences due to the distribution of scores; females scored the items ‘health’, ‘sleeping’,
and ‘economy’ as bad to a larger extent than males (Table 3). Males were
signiﬁcantly more dependent than females in three out of nine ADL: ‘going to the
toilet’, ‘dressing’, and ‘cooking’ (Table 4). Analyses of the separate subjective
Table 1
Descriptive data of a Swedish sample of elderly patients, aged 65–95 years, at the beginning of their
rehabilitation period (N= 244)
Descriptive characteristics

Total study sample (N= 244)
%

Females (n= 145)
%

Males (n = 97)
%

Ci6il status
Single
Married or cohabiting
Widowed

15
42
43

15
26
59

15
66
19

Li6ing conditions
Sheltered housing
Ordinary housing

41
59

48
52

31
69

C. Nygren et al. / Arch. Gerontol. Geriatr. 30 (2000) 173–184

179

Table 2
Median scores of the ratings of separate items of the subjective well-being scalea in a Swedish sample
of elderly patients, aged 65–95 years, at the beginning of their rehabilitation period (N =244)
Subjective well-being
subscale

Subjective well-being item

Total sample

Females

Males

N =244

n = 145

n =99

Md b

Md b

Md b

Health
Fitness
Hearing
Vision
Memory
Appetite

4
4
5
5
5
6

4
4
5
5
6
6

4
4
5
5
5
6

Mood
Energy
Endurance
Self-esteem
Sleeping

6
5
6
5
6

5
5
5
5
5

6
5
6
5
6

Family
Economy
Housing
Leisure
Sense of signiﬁcance at home
Sense of signiﬁcance outside
home

6
5
6
5
7
6

6
5
6
5
7
6

7
5
7
5
6
6

Physical well-being

Mental well-being

Social well-being

a
From the Goteborg Quality of Life Instrument (Tibblin et al., 1990). For this study a later version
¨
of the instrument, comprising three more items was used (Iwarsson and Isacsson, 1997a).
b
Results from subjective ratings on an ordinal scale ranging from 1 ( = ‘very bad’) to 7 ( =‘excellent’
couldn’t be better).

well-being items and ADL dependence showed signiﬁcant correlations for females
in the item ‘energy’ (P =0.018) and for males in the items ‘ﬁtness’ (P= 0.046) and
‘energy’ (P =0.041).

4. Discussion
The results of this study showed that a group of geriatric patients at the
beginning of their rehabilitation period rated their subjective well-being rather high,
in spite of substantial dependence in ADL, and that there was no signiﬁcant
covariance between ADL dependence and summed subjective well-being. This result
was unexpected, since previous studies indicated such relationships (Noro and Aro,

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C. Nygren et al. / Arch. Gerontol. Geriatr. 30 (2000) 173–184

1996), e.g. in a gerontological population sample of the same age from one of the
municipalities of the same study district, using the same instruments (Iwarsson and
Isacsson, 1997a,b). On the other hand, when the proportions of ADL dependence
Table 3
Gender differences in distribution of ratings of separate items of the subjective well-being scalea in a
Swedish sample of elderly patients, aged 65–95 years, at the beginning of their rehabilitation period
(N =244), females (n =145) and males (n = 99)
Subjective well-being item

Gender

Distribution of ratingsb

P-value

Excellent/good

Neither good/bad

Bad

%

%

%

Females
Males

28
43

32
30

40
27

0.022

Females
Males

56
75

23
13

21
12

0.013

Females
Males

56
74

23
22

21
4

0.023

Health

Sleeping

Economy

a
From the Goteborg Quality of Life Instrument (Tibblin et al., 1990). For this study a later version
¨
of the instrument, comprising three more items was used (Iwarsson and Isacsson, 1997a).
b
Results from subjective ratings on an seven step ordinal scale, trichotomised as 1–3 ( =‘bad’), 4
( =neither good or bad) and 5–7 (‘excellent/good’).

Table 4
Gender differences in ratio of dependence in the separate activities of the ADL Staircasea in a Swedish
sample of elderly patients, age 65–95 years, at the beginning of their rehabilitation period (N =244)
ADL

Gender differences P-value
Total sample

n= 145

n= 99

N =244

%
Feeding
Transfer
Going to the toilet
Dressing
Bathing
Cooking
Shopping
Cleaning
Transportation

Ratio of dependence
Females
Males

%

%

1
30
34
41
59
61
85
88
92

0
38
48
54
64
89
90
92
88

1
34
39
47
61
72
87
89
90

ns
ns
0.032
0.043
ns
B0.0005
ns
ns
ns

a
,
(Sonn and Hulter-Asberg, 1991). For this study a revised version of the instrument, comprising an
alternative item for transportation was used (Iwarsson and Isacsson, 1997b).

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181

and the scores of summed subjective well-being in the current study and the
previous ones were compared, this patient sample, as expected, showed considerably higher proportions of dependence in ADL, as well as lower subjective
well-being.
In this study no signiﬁcant correlation between the single item ‘health’ from the
physical well-being scale and dependence in ADL occurred, neither for the whole
study sample nor for either of the gender groups. In contrast to this, gerontological
studies have shown that performance and independence in ADL are positively
related to health (Clark et al., 1998; Era and Rantanen, 1998), subjective well-being
(Iwarsson and Isacsson, 1997a), and survival (Iwarsson et al., 1997). Most likely,
health has a different meaning for elderly patients at the beginning of a rehabilitation process than for a gerontological population maintaining their everyday life.
Even so, some signiﬁcant correlations were found between separate subjective
well-being items and ADL dependence. This shows the value of the assessment of
subjective well-being and ADL dependence at the beginning of a rehabilitation
process, since the results could be used for input to rehabilitation planning. The
absence of signiﬁcant correlations between items from the physical well-being scale
and ADL dependence reﬂected the importance of considering other areas of
well-being, e.g. mental and social factors (Hoenig et al., 1997). A focus on mental
energy, leisure activities, and social activities at the beginning of a rehabilitation
period could presumably make the process more efﬁcient, setting goals in accordance with the patients’s needs.
The covariance between ADL dependence and the item ‘energy’ from the mental
well-being scale is probably because the patients had recently started their rehabilitation, and had to cope with a new situation, taking a lot of energy. Since
dependence in ADL covaried with ‘leisure’ and ‘sense of signiﬁcance and appreciation outside home’ as well, there seems to be a risk of loss of meaningful activities
and relations to signiﬁcant others. A loss of social roles most often causes a weaker
and narrowed social network (Kurlowicz, 1993; Clark et al., 1998). As regards the
signiﬁcant correlation between ‘leisure’ and ADL dependence, it does not have to
be related to mental and social well-being only. In a population study of old people
(Iwarsson and Isacsson, 1997a), using the same instruments, a signiﬁcant correlation between the accessibility of the housing environment and ‘leisure’ indicated a
need for further investigation into how the physical environment (Lawton, 1983,
1991) affects subjective well-being.
The only signiﬁcant correlation between ADL dependence and a single physical
well-being item, viz. ‘ﬁtness’, occurred in the male sub-sample, indicating that the
general assumption about the covariation between ﬁtness and ADL dependence
(Birren et al., 1991; Grimby and Wijklund, 1994) could be related to gender
(Iwarsson and Isacsson, 1997a). In addition, the conclusion that elderly females, in
spite of their higher morbidity, maintain and perform ADL to a larger extent than
males (Helset, 1993; Sarwari et al., 1998) was reﬂected in this study. However, since
the items of ADL instruments are not neutral for gender (Iwarsson et al., 1997;
Iwarsson, 1998), further exploration in order to control for methodological bias is
called for.

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An obvious limitation of this study is the fact that exact data on diagnoses
according to the ICD IX were not gathered, due to the fact that this kind of
information was not always available to the local rehabilitation teams. Instead,
symptom diagnoses were used, such as rehabilitation after stroke, after hip fracture
or ‘general mobilization’. Diagnosis inﬂuences the rehabilitation process and is an
important factor to consider in any treatment planning. Still, the same diagnoses
can include differing functional abilities. Furthermore, the majority of studies in the
ﬁeld of rehabilitation focus diagnose speciﬁc samples. The sample of this study
represents a genuine, not idealised geriatric rehabilitation sample, including different diagnoses and different levels of care (Nygren et al., submitted).
Even though as many as 50 practising occupational therapists and physiotherapists were used as data collectors, the data produced on ADL dependence reached
the measurement standards required. Collecting data of high quality in clinical
reality requires certain efforts (Iwarsson, 1998; Nygren et al., submitted), and the
methodological seminars given by the authors probably counteracted the source of
errors that the use of many data collectors usually implies. The high values of COR
(Guttman, 1950), and COS (Menzel, 1953) demonstrated in the current study
indicate that we succeeded in gathering data with quite sufﬁcient reliability and
validity.
One possible explanation for the non-existing but expected covariance between
ADL dependence and summed subjective well-being might be given by the distribution of data. The majority of the subjective well-being items measured showed
similar and rather high medians. Responses to this kind of scales tend to cluster
against the mean rating alternative, but on the other hand the data distributions
were similar in previous studies (Iwarsson and Isacsson, 1997a). A fact supporting
this explanation anyhow is that the few items that showed covariance between
subjective well-being and ADL dependence demonstrated wider data distributions
with a higher proportion of ratings below the median value in comparison with the
remaining items. Furthermore, it could be argued that the varying number of
dropouts, due to incomplete answers to the subjective well-being scale, contributed
to the non-existing covariance. The questionnaire was self-administered, and most
likely some of the elderly respondents in this study had difﬁculties even though they
were guided by a therapist, highlighting the speciﬁc difﬁculties of data collection
with frail individuals. Still, previous studies from the same study district, based on
a sample half the size of that in the current study, showed covariance between
summed subjective well-being and ADL dependence (Iwarsson and Isacsson,
1997a), indicating that population size is a minor explanation for the unexpected
result of this study.
In conclusion, the results on ADL dependence and subjective well-being at the
beginning of the rehabilitation process presented show the importance of gaining
additional knowledge for the planning and development of geriatric rehabilitation
services. Based on the ﬁndings of this study, the targeting of patient needs requires
re-evaluation, challenging the traditional goal-setting and evaluation procedures of
current geriatric rehabilitation services.

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183

Acknowledgements
Thanks to all the occupational therapists and physiotherapists in Kristianstad
County, Sweden, who collected data for this study, for their valuable contribution.
We are grateful to Kristianstad County Council for ﬁnancial support. Finally, we
,
wish to thank our colleague, the late Ake Isacsson, Associate Professor, for his
valuable contribution to this project.

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