2025 Volume 10 Article ID: 20250005
Objectives: In an ultra-aged society, the increasing number of elderly individuals requiring nursing care because of complications and disabilities poses a significant challenge for healthcare providers, along with a decline in the quality of life (QoL). Therefore, investigating the underlying causes and establishing effective preventive measures is imperative. Sarcopenia, characterized by a reduction in muscle strength throughout the body, can negatively impact QoL because of declining physical function. This study aimed to elucidate the interrelationship between physical function and health-related quality of life (HRQoL) in elderly individuals requiring long-term care.
Methods: The participants (n=67) were elderly individuals (32 men, 35 women) requiring light nursing care. HRQoL was assessed using the EuroQol Group 5-Dimensions 5-Level (EQ-5D-5L) scale. Relationships between the EQ-5D-5L score and age, body mass index, SARC-CalF, and sex were examined. The relationships between the EQ-5D-5L score and the 10-s chair stand test, functional reach test (FRT), grip strength, 10-m walking test, and Timed Up-and-Go (TUG) test were investigated separately for men and women.
Results: A correlation was identified between EQ-5D-5L score and sex. In men, a correlation was identified between EQ-5D-5L and TUG test results. In women, a comparable correlation was observed between EQ-5D-5L score and the 10-m walking test, FRT, and TUG test.
Conclusions: The findings revealed a correlation between physical functions, including standing and walking, and QoL in elderly individuals requiring light nursing care. Maintaining and enhancing standing and walking abilities among this demographic group should be a high priority.
As in other countries, Japan has experienced a rapid demographic shift in recent decades, with the proportion of the population aged 65 years and above increasing consistently from 4.9% in 1950. Projections indicated that the proportion of the population aged 65 years and above would exceed 10% in 1985, 20% in 2005, and 28.4% in 2018, reaching 35.3% by 2040.1) As they age, older adults frequently experience complications, disabilities, and diminished quality of life (QoL).2) QoL is a multidimensional, subjective construct. In 1994, the World Health Organization (WHO) defined it as “a perception of one’s life situation related to goals, expectations, standards, and interests in the culture and values of an individual’s life.” It is associated with personal well-being and encompasses a multitude of elements, including health, leisure, personal fulfillment, habits, and lifestyles. Moreover, QoL is regarded as a pivotal element in the process of healthy aging, because the probability of developing chronic illnesses and ultimately dying is significantly reduced among adults who report high levels of life satisfaction.3) Accordingly, the maintenance of a favorable QoL is crucial for overall public health, particularly in the context of older adults. However, the number of elderly individuals requiring nursing care is increasing because of the prevalence of complications and the extent of disability. Concerns are growing regarding a decline in QoL resulting from a decline in activities of daily living (ADL), motivation, and hindrance to physical and psychological health. However, the precise mechanism of these declines remains unclear. A more comprehensive understanding of the elements that precipitate a diminution in the QoL of elderly individuals who require nursing care will prove advantageous not only for these individuals themselves but also for the formulation of strategies aimed at maintaining the health of their caregivers. Accordingly, conducting objective QoL assessments using various scales is essential. The EuroQoL-5 Dimensions-5 Levels (EQ-5D-5L) is a self-administered evaluation scale that has been developed for the purpose of measuring health-related quality of life (HRQoL). The EQ-5D-5L is employed in a variety of contexts, including the assessment of clinical outcomes, evaluation of medical economic research, and the calculation of utility indices for medical interventions. Given that validity reports have been obtained in Europe, the USA, and Asia,4,5) we elected to evaluate HRQoL in older adults using the Japanese version of the EQ-5D-5L.6) In recent years, sarcopenia, a condition characterized by a decline in skeletal muscle mass and strength with age, has emerged as a significant concern in gerontology. In individuals with sarcopenia, symptoms such as dizziness and falls may result from a decline in physical functions, including standing and walking. This can result in a need for nursing care and adversely affect QoL.
This study aimed to examine the relationship between QoL of elderly individuals requiring light-level care and various physical functions, including grip strength and gait and standing tests used for diagnosing sarcopenia. It also aimed to elucidate the factors influencing QoL in an elderly population. This physical function assessment is well-suited for elderly individuals requiring care, such as the subjects of this study, because it can be conducted in a safe and straightforward manner without an undue burden on the test subjects. Furthermore, considering the documented sex-based disparities in muscle mass and strength, the analysis was conducted in a sex-specific manner with male and female subjects evaluated separately. By elucidating this association, further insight may be gained regarding the development of methods for older adults to maintain a healthy high-quality lifestyle, thereby providing important public health findings.
The long-term care insurance system in Japan provides financial support to individuals and their families experiencing anxiety and the burden of long-term care. The certification of long-term care can be divided into the following categories according to the physical condition of the individual: independent state, support-requiring state (future long-term care may be necessary for housework and daily life), and long-term care required (being bedridden, having dementia, and similar conditions) (Table 1).
| Classificationa | Physical condition |
| Not eligible | The individual can perform essential daily life activities and task-based activities without assistance and needs neither support nor care. |
| Requiring support | |
| 1 | The individual can rise, walk, and perform most essential daily life activities without assistance. However, the person needs some support for task-based activities in daily life, including cooking, shopping, and taking oral medications. |
| 2 | The ability of the individual to handle task-based activities in daily life is slightly lower than that of individuals in the support required 1 category, and he/she needs more support. |
| Requiring long-term care | |
| 1 | The individual faces difficulty in performing essential activities of daily life without assistance. The person’s ability to handle task-based activities in daily life is lower than that of individuals in the support required 2 category. |
| 2 | The individual is in a state similar to that of requiring long-term care 1 but requires more care to be able to perform essential daily living activities. |
| 3 | Compared with the state of requiring long-term care 2, the ability of the individual to perform essential daily life activities and task-based activities is significantly lower. He/she requires almost constant care. |
| 4 | The individual is in a state similar to that detailed under requiring long-term care 3, but his/her ability to act is lower. He/she faces difficulty living without constant care. |
| 5 | The ability of the individual to act is lower than that of individuals in the long-term care 4 category. He/she requires almost constant care to live. |
a Classification of certification for long-term care.
Participants in this study were selected from a pool of elderly individuals residing in the community who had been certified as requiring long-term care at Katsuragi Hospital and possessed the requisite mobility to commute to or visit the hospital for outpatient care. A total of 67 participants were recruited and each provided consent to participate in this study. The following mean data were collected: age, 79 ± 9 years (range: 64–91 years); height, 156.7 ± 10.1 cm; weight, 57.0 ± 9.6 kg; body mass index (BMI), 23.4 ± 4.4 kg/m2. Nine cases were classified as requiring support level 1, 29 as requiring support level 2, 11 as requiring long-term care level 1, 7 as requiring long-term care level 2, and 11 as requiring long-term care level 3. The cohort included 32 men and 35 women (Table 2).
| Parameter | Total | Male | Female |
| n | 67 (100%) | 32 (48%) | 35 (52%) |
| Age, years | 79±9 | 77±10 | 81±7 |
| Height, cm | 156.7±10.1 | 164.7±7.9 | 149.3±5.1 |
| Weight, kg | 57.0±9.6 | 57.7±9.2 | 56.3±10 |
| BMI, kg/m2 | 23.4±4.4 | 21.3±3.3 | 25.2±4.5 |
| Certification for long-term care | |||
| Requiring support 1 | 9 (13%) | 5 (16%) | 4 (11%) |
| Requiring support 2 | 29 (43%) | 12 (38%) | 17 (49%) |
| Requiring long-term care 1 | 11 (16%) | 7 (22%) | 4 (11%) |
| Requiring long-term care 2 | 7 (10%) | 3 (9%) | 4 (11%) |
| Requiring long-term care 3 | 11 (16%) | 5 (16%) | 6 (17%) |
Data given as number (percentage) or mean ± standard deviation (SD).
To be eligible for inclusion in the study, participants had to meet the following criteria: they had undergone outpatient rehabilitation on two or three occasions per week, scored 22 points or above on the Mini-Mental State Examination (MMSE), and had nursing care needs primarily related to the deterioration of their physical function. Individuals with an MMSE score of 21 or less were excluded from the study because this score indicated a suspected case of dementia or cognitive impairment. Furthermore, participants were excluded if they were unable to complete a physical function test because of a disability.
This study was approved by the Ethics Committee of Katsuragi Hospital (#71). The participants demonstrated sufficient cognitive function to comprehend the explanations and provide consent. Written informed consent was obtained from all participants.
Health Status Using the EQ-5D-5L InstrumentThe EQ-5D-5L was employed as an index of HRQoL. The EQ-5D-5L was self-administered by participants to assess their health status. The five items of health status, “degree of movement,” “management of personal belongings,” “ordinary activity,” “pain/discomfort,” and “anxiety/blocking,” are expressed on a scale of one to five, resulting in a total of 3125 possible health states, ranging from “11111” to “55555.” When all items are scored as 1, the resulting score of 11111 represents the highest possible score. The QoL value was obtained by subtracting the estimated value from 1 at each stage for the five items. Because each country employs its own estimate, the EQ-5D-5L score varies from one country to another for the same health condition.6) To illustrate, the score of 11314 represents the following state: degree of movement, able to walk around without difficulty (1); management of personal belongings, able to wash and change clothes independently (1); normal activity, moderate difficulty in performing routine activities (3); pain/discomfort, no pain or discomfort (1); anxiety/blocking, significant anxiety or a sense of being blocked (4). In accordance with Japanese estimates, the score for “ordinary activity” is –0.091131, while the score for “anxiety/blocking” is –0.168171. When these values are subtracted from 1, the resulting score is 0.741. The EQ-5D-5L utility score was calculated according to estimated Japanese values. Subjects with an EQ-5D-5L utility score less than 0.8 were assigned to the low-QoL group, whereas those with a score of 0.8 or above were assigned to the high-QoL group.
Physical Function AssessmentsPhysical function was evaluated using the 10-s chair stand test, functional reach test (FRT), grip strength, 10-m walking test, Timed Up-and-Go (TUG) test, and lower leg circumference. In the 10-s chair stand test, the subjects were seated in a chair with their arms crossed in front of their chest, and the number of times they rose to a standing position in 10 s was recorded. In the standing position, the knees were fully extended, and in the seated position, the buttocks were placed on the seat. This enables the evaluation of lower-limb muscle strength.7) The FRT is used to measure an individual’s balance ability. The subject was instructed to raise one upper limb to a height of 90° shoulder flexion while standing and then reach forward as far as possible. This distance was also recorded.8) The 10-m walking test measures an individual’s capacity to walk 10 m within a given time. The subject was required to walk from the starting line to the goal line, and the time required to complete the task was recorded.9) The TUG test is a comprehensive assessment tool that evaluates multiple domains, including lower limb muscle strength, balance, walking ability, and other daily living functions, including the tendency to fall easily. It is conducted by measuring the time required for the subject to sit down in a chair, stand up, walk to a 3-m marker, turn around, and return to their starting position.10) Lower leg circumference was measured along the maximum perimeter of the calf. In addition to the aforementioned motor functions, the SARC-CalF score was also evaluated. The SARC-CalF comprises items from the SARC-F, including those pertaining to strength, assistance with walking, rising from a chair, climbing stairs, falling, and lower leg circumference. A score of 11 or higher indicates a high probability of skeletal muscle mass loss. SARC-F was recommended by the Asian Working Group for Sarcopenia 2019.11)
Statistical AnalysisA Student’s t-test was used to evaluate the differences in EQ-5D-5L utility scores, physical function, lower limb circumference, and SARC-CalF scores between male and female subjects. Subsequently, the correlations between the EQ-5D-5L and age, body mass index (BMI), and SARC-CalF were analyzed by determining Pearson’s correlation coefficient (r). The relationship between EQ-5D-5L scores and sex was investigated using Fisher’s exact test. Pearson’s correlation coefficient was used to examine the correlation between each EQ-5D-5L utility score and physical function in the male and female participants. Moreover, discrepancies in the degree of care required, age, EQ-5D-5L utility score, each physical function, and SARC-CalF between the low-QoL and high-QoL groups in males and females were investigated using Student’s t-tests. All statistical analyses were conducted using GraphPad Prism Version 9.1.0 (221) (GraphPad Software, San Diego, USA), and P <0.05 was considered to indicate statistical significance.
The findings revealed that in comparison with the male cohort, the female cohort exhibited markedly reduced scores for EQ-5D-5L utility, the 10-s chair stand test, FRT, grip strength, lower limb circumference, and SARC-CalF (Table 3). No correlation was identified between age and EQ-5D-5L utility score (P = 0.335). No correlation was identified between BMI and EQ-5D-5L utility score (P = 0.217). The mean SARC-CalF score for all participants was 7.9 ± 5.2, with 26 patients exhibiting a score of 11 or above. Furthermore, no correlation was identified between SARC-CalF and EQ-5D-5L utility scores (P = 0.073). However, a significant difference was observed between the sexes (P = 0.02) for EQ-5D-5L utility score (men, 0.83 ± 0.17; women, 0.73 ± 0.18). The participants were divided into two groups based on sex, and the correlations between the EQ-5D-5L utility score and five items of motor function (10-s chair stand test, FRT, grip strength, 10-m walking test, and TUG test) were examined. The correlation coefficient of the TUG test was −0.438 [95% confidence interval (CI): −0.682 to −0.105; P = 0.0122], indicating a negative and statistically significant correlation in the male cohort (Fig. 1).
| Parameter | Total | Male | Female | P value |
| EQ-5D-5L utility score | 0.779±0.179 | 0.833±0.169 | 0.730±0.176 | 0.035* |
| 10-s chair stand test, times | 4±0 | 4±1 | 3±2 | 0.044* |
| FRT, cm | 21±7 | 23±6 | 20±7 | 0.049* |
| Grip strength, kg | 23.8±7.4 | 28.6±6.2 | 19.6±5.1 | <0.01* |
| 10-m walk test, s | 14.6±7.4 | 13.1±5.2 | 16.5±8.8 | 0.064 |
| TUG test, s | 18.7±10.2 | 17.7±10.4 | 20.1±10.2 | 0.205 |
| Circumference of lower leg, cm | 32.8±4.9 | 32.0±3.4 | 34.3±3.1 | 0.012* |
| SARC-CalF | 8±5 | 9±5 | 7±5 | <0.01* |
Data given as mean ± SD.
* Statistically significant (P < 0.05).
Correlation scatterplots between EQ-5D-5L scores and physical functions in male participants. (A) 10-s chair stand test; (B) FRT; (C) grip strength; (D) 10-m walk test; (E) TUG test.
In the female cohort, a significant positive correlation was observed with FRT (r = 0.448, 95% CI: 0.129–0.683; P = 0.00789). A significant negative correlation was observed between the 10-m walking test and the EQ-5D-5L utility score (r = −0.443, 95% CI: −0.78 to –0.339; P = 0.000122). Furthermore, a significant negative correlation was identified between the TUG test and EQ-5D-5L utility score (95% CI: −0.677 to −0.129, P = 0.00765) (Fig. 2).
Correlation scatterplots between EQ-5D-5L scores and physical function in female participants. (A) 10-s chair stand test; (B) FRT; (C) grip strength; (D) 10-m walk test; (E) TUG test.
A comparison of the low-QoL group (EQ-5D-5L utility score < 0.8) with the high-QoL group (EQ-5D-5L utility score > 0.8) in men revealed no significant differences in the level of care required, age, BMI, 10-s chair stand test, FRT, grip strength, 10-m walking test, lower leg circumference, or SARC-CalF score between the two groups. However, a significant difference was observed for the TUG test (low QWoL, 23.3 ± 15.0 s; high QoL, 14.7 ± 5.3 s; P = 0.023) (Table 4).
| Physical assessment | Low-QoL groupa (n=11) | High-QoL groupb (n=21) | P value |
| Certification for long-term care 1/2/3/4/5 | 0/6/2/1/2 | 5/6/5/2/3 | 0.393 |
| Age, years | 75±10 | 78±10 | 0.512 |
| BMI, kg/m2 | 21.6±3.0 | 21.8±3.2 | 0.917 |
| 10-s chair stand test, times | 3±1 | 4±1 | 0.166 |
| FRT, cm | 23±6 | 23±6 | 0.938 |
| Grip strength, kg | 27.2±7.2 | 29.4±5.6 | 0.342 |
| 10-m walk test, s | 14.8±5.7 | 12.2±4.8 | 0.183 |
| TUG test, s | 23.3±15.0 | 14.7±5.3 | 0.023* |
| Circumference of lower leg, cm | 31.6±3.2 | 32.2±3.5 | 0.673 |
| SARC-CalF | 9±6 | 9±5 | 0.771 |
Data given as number or mean ± SD.
a EQ-5D-5L utility score < 0.8; b EQ-5D-5L utility score ≥ 0.8.
* Statistically significant (P < 0.05).
In the female cohort, no significant differences were observed in the level of care required, age, BMI, 10-s chair stand test, grip strength, TUG test, lower leg circumference, or SARC-CalF score between the low-QoL and high-QoL groups. However, a significant difference was observed in the FRT (low QWoL, 17 ± 6 cm; high QoL, 23 ± 7 cm; P = 0.001). Furthermore, the 10-m walking test demonstrated a statistically significant difference between the low-QoL group (19.0 ± 10.0 s) and the high-QoL group (12.6 ± 5.0 s) (P = 0.033) (Table 5).
| Physical assessment | Low-QoL groupa (n=21) | High-QoL groupb (n=14) | P value |
| Certification for long-term care 1/2/3/4/5 | 1/9/2/4/5 | 3/8/2/0/1 | 0.159 |
| Age, years | 79±9 | 82±5 | 0.239 |
| BMI, kg/m2 | 26±5.2 | 23.6±3 | 0.129 |
| 10-s chair stand test, times | 3±2 | 3±2 | 0.526 |
| FRT, cm | 17±6 | 23±7 | 0.011* |
| Grip strength, kg | 19.3±5.5 | 20.1±4.6 | 0.662 |
| 10-m walk test, s | 19.0±10.0 | 12.6±5.0 | 0.033* |
| TUG test, s | 22.0±10.1 | 17.3±9.9 | 0.184 |
| Circumference of lower leg, cm | 34.4±3.6 | 34.3±2.3 | 0.955 |
| SARC-CalF | 8±5 | 5±5 | 0.144 |
Data given as number or mean ± SD.
a EQ-5D-5L utility score < 0.8; b EQ-5D-5L utility score ≥ 0.8.
* Statistically significant (P < 0.05).
This study investigated the relationship between sex and HRQoL in elderly individuals requiring light nursing care. We examined the correlation between each physical function test used for the diagnosis of sarcopenia and HRQoL stratified by sex. The results revealed a statistically significant correlation between the EQ-5D-5L utility score and the TUG test in men, as well as between the EQ-5D-5L utility score and the FRT, 10-m walking test, and TUG test in women. The TUG test comprises four distinct movements: standing up, walking, changing direction, and sitting down. This provides a comprehensive evaluation of dynamic balance, lower limb muscle strength, coordination, and recovery response. The 10-m walking test is an effective method for evaluating walking ability, whereas the FRT is a reliable indicator of dynamic balance ability. Our findings suggest that reduced ability to stand, walk, and maintain balance is associated with a reduction in QoL among both male and female individuals who require some degree of care. In elderly individuals who require minor nursing care for conditions such as stroke, dementia, joint disease, falls, or fractures, physical functions such as standing and walking may play a significant role in maintaining HRQoL.
The advent of the long-term care insurance system has led to a notable increase in the number of individuals requiring long-term care, underscoring the pressing need to prevent, maintain, and enhance it. Conversely, the QoL of individuals requiring long-term care declines owing to factors such as declining health, loss of physical function, and mental distress. Investigations of these factors have been conducted in other countries, as evidenced by published reports. Previous studies have examined the relationships between QoL and physical function assessments such as the short physical performance battery, fast walking speed, muscle mass, and physical performance, which were also used by the Asian Working Group for Sarcopenia 2019 in sarcopenia diagnosis.12,13,14,15) These reports demonstrated a correlation between a decline in QoL and physical ability in the elderly. In contrast, the EQ-5D, which serves as an indicator of HRQoL, was developed by the EuroQol Group, a research consortium established in 1987. It comprises five items that assess health status. The EQ-5D is a straightforward instrument that places a minimal burden on patients when surveyed, thus facilitating its use in clinical settings. It is available in numerous languages and used globally. The QoL value was calculated using a conversion table, and the Japanese version has the ability to calculate QoL values that reflect Japanese values with high sensitivity.6,16) In the USA, the QoL evaluation was conducted using the EQ-5D-5L instrument on a relatively young cohort of individuals aged 50–69 years with arthritis. Furthermore, reports have indicated a correlation between 6-min walking distance and QoL values.17) Moreover, the EQ-5D-5L has been shown to be an effective tool for assessing QoL of older adults with dementia.18) Therefore, this study employed the Japanese version of the EQ-5D-5L, which reflects Japanese values, as a method for evaluating the QoL of individuals requiring long-term care. In previous studies that investigated the impact of QoL on more than 48,000 elderly individuals, a decline in QoL with age was observed, irrespective of sex.19) In the present study, we investigated the correlation between EQ-5D-5L utility scores and BMI, age, and sex in a group of 67 elderly individuals (average age 79 years) who were able to attend hospitals and nursing homes and showed no significant cognitive decline. Our findings indicated no correlation between the EQ-5D-5L utility score and age or BMI, which are indicators of nutritional status. However, a correlation was identified between the EQ-5D-5L utility score and sex. Although there was no age difference between male and female participants, woman may have different roles at home or may engage in different leisure activities from those of men, and this point of difference in the study population may have contributed to the observed differences. Considering the well-documented differences in muscle mass and strength between men and women, as well as sex differences in QoL, the results of this study revealed sex differences in several factors, including the 10-s chair stand test, FRT, grip strength, and SARC-CalF score. Consequently, the analysis was conducted according to sex.
This study has several limitations. First, the sample size was relatively small (n = 67), which may limit our ability to extrapolate our findings to other populations. Second, the underlying cause of the participants’ need for long-term care was not identified. Furthermore, we did not measure muscle mass by dual-energy X-ray absorptiometry or bioelectrical impedance analysis, which limits our ability to ascertain the relationship between sarcopenia and QoL. Despite these limitations, our findings show that physical functions such as standing and walking are associated with the quality of life in elderly individuals who require minor nursing care.
The authors thank Editage (http://www.editage.com) for English language editing.
The authors declare no conflict of interest.
