Determinants of Quality of Life Among Older Adults in a Social Care Center: Emphasis on Sleep

Introduction

Aging is a natural and inevitable phase in human development, marked by progressive physical, psychological, and social changes that often result in gradual decline. According to the World Health Organization,¹ individuals aged 60 years and above are classified as elderly. This phase of life presents challenges such as reduced adaptability to stress, decreased biological and cognitive function, and diminished social interaction, all of which may significantly affect an individual’s quality of life (QoL).² However, aging should not be viewed solely as a period of decline. With adequate health care, meaningful daily activities, and supportive living environments, many older adults are able to maintain independence, resilience, and a sense of well-being. Thus, understanding the multidimensional impact of aging is essential for developing strategies that promote active aging and improve QoL among the elderly population.

In Indonesia, caring for the elderly has traditionally been considered a familial responsibility, deeply rooted in cultural values of parental respect and intergenerational support. However, changes in family dynamics, rapid urbanization, and increasing work demands have shifted this paradigm, resulting in a growing number of elderlies being placed in nursing homes or social care centers.³ While these institutions provide essential health and social services, the transition to institutional living often comes at a psychosocial cost. Many elderly residents report feelings of loneliness, abandonment, and diminished self-worth, particularly when the decision to institutionalize is made without their full consent or participation.⁴ Such experiences not only affect emotional well-being but can also significantly lower overall quality of life, underscoring the need for more person-centered and family-inclusive approaches in elderly care.

Quality of life among institutionalized elderly is influenced by multiple factors, including physical health, mental well-being, and social connectedness. Living in residential care facilities can shape how older adults experience daily life, particularly in relation to autonomy, participation in activities, and engagement with others within the institution.⁵ A lack of meaningful interaction can lead to isolation, depression, and poor QoL among residents in social care facilities.⁶ Studies have suggested that positive social environments and meaningful engagement can buffer the negative impact of institutionalization. When elderly individuals experience regular interaction with family, peers, and the broader community, their sense of purpose and emotional resilience improves. Moreover, opportunities for interaction, recreation, and companionship, together with healthy daily habits, can significantly enhance their perception of life satisfaction and reduce psychological distress.⁷

A preliminary exploration at Tresna Werdha Budi Mulia 2 Social Care Center in Jakarta revealed that residents often felt bored, lonely, and disconnected due to the limited variety of daily activities and minimal opportunities for meaningful interaction. These psychosocial challenges illustrate how institutional living can restrict autonomy and reduce the sense of purpose among the elderly, which in turn may negatively influence their overall quality of life. Motivated by these observations, the present study seeks to explore factors related to the well-being of older adult individuals residing in social care centers. In this context, the research is directed toward understanding whether, and to what extent, health-related factors such as treatment adherence, nutritional status, sleep pattern, and physical activity can enhance different dimensions of quality of life, including physical health, psychological well-being, and social connectedness. By examining various health-related factors, the study aims to provide a clearer understanding of determinants that contribute to the lived experiences and overall well-being of older adults residing in social care facilities.

Methods

This study employed a cross-sectional design using a non-probability purposive sampling technique to recruit older adults individuals residing in Tresna Werdha Budi Mulia 2 Social Care Center, West Jakarta. Participants were selected based on specific inclusion and exclusion criteria to ensure the appropriateness of the sample for the research objectives. Data collection was conducted in August 2022 at Tresna Werdha Budi Mulia 2 Social Care Center, Cengkareng, West Jakarta.

The inclusion criteria were as follows: (a) participants who had been residing in the care center for more than one month, (b) aged 46 years or older, and (c) not experiencing severe illness, dementia, severe hearing impairment, major psychological disorders, or impaired consciousness. The exclusion criteria included: (a) individuals with communication disorders that could hinder participations, and (b) residents who were unwilling to participate.

The World Health Organization defines older adults as individuals aged 60 years and above, this study included participants aged 46 years and older to capture early ageing stages. For analytical purposes, participants were categorized into middle-to-older age group (46 – 55 years) and older age group (56 – 65 years). Participants demonstrated mild to moderate levels of dependency but were able to perform basic activities of daily living independently.

Data collection utilized two main instruments. First, demographic data were collected using a standardized questionnaire from the World Health Organization. Second, quality of life was assesed using the World Health Organization Quality of Life-BREF (WHOQOL-BREF) questionnaire, which measures four domains: physical, psychological, social, and environmental. Quality of life scores were categorized into three levels: low (<33), moderate (≥33 and <67), and high (≥67). Additionally, the Quality-of-Life Index: Generic Version-III was used to support and compare WHOQOL-BREF findings. Health-related behaviours were assessed using structured interview questions administered by the research team. Five domains were evaluated: medication adherence, sleep patterns, nutritional intake, disease prevention practices, and physical exercise. Each domain consisted of four subjective questions related to participant’s daily health practices. Responses were recorded based on participant’s self-reported experiences and were subsequently categorized into two levels (fair and good) according to predefined criteria for analysis.

Additional health-related behaviors, including sleep quality, nutritional intake, and disease prevention activities, were assessed descriptively using structured self-reported items to provide contextual information supporting QoL interpretation. These variables were not intended as primary outcome measures but served as complementary indicators of daily functioning.

Data analysis consisted of univariate and bivariate methods. Univariate analysis was conducted to describe demographic variables such as age, gender, education, marital status, and employment. Bivariate analysis was conducted using Fisher’s Exact Test to examine the associations between categorical variables, including health-related factors and overall quality of life, as several contingency table cells had small expected counts.

The Participant Information Sheet (PIS) and informed consent were verbally administered by the research team, as most participants were older adults and some had visual impairments. Following a detailed verbal explanation and confirmation of comprehension, participants who voluntarily agreed to take part provided their written signatures on the consent form. This procedure was reviewed and approved by the institutional ethics committee to ensure inclusivity, accessibility, and full understanding among all participants.

Results

Discussion

Quality of life is defined as an individual’s perception of their position in life, in the context of their goals, expectations, and social and cultural values.² It is a broad, multidimensional concept that includes subjective evaluations of both positive and negative aspects of life.⁵ Among the older adults, QoL is influenced by several interrelated factors, such as physical health, psychological well-being, social support, and environmental conditions. In addition, the World Health Organization emphasizes that QoL is not only merely related to the absence of disease but also reflects overall well-being, independence, social relationships, and spiritual aspects. QoL is a dynamic construct that can change over time in response to shifts in health status, life roles, or socioeconomic circumstances. As such, measuring QoL provides a comprehensive indicator of an individual’s overall health and serves as an essential outcome in evaluating the effectiveness of healthcare interventions and social policies.

In this study, the majority of older adult residents in the social care center were married, had an adequate nutritional intake, and were actively engaged in disease prevention activities. The result also showed that most participants were categorized as having good QoL. Nevertheless, variations in perceived well-being may still occur among instutionalized older adults despite favourable health-related behavior. Previous research has reported that 68.4% of older adults in their study had poor QoL.⁵ This suggests that objective indicators do not necessarily guarantee subjective well-being. Factors such as loneliness, declining physical capacity, loss of independence, or unmet emotional needs may influence how older adults perceive their quality of life.⁸ Therefore, QoL assessment should adopt a holistic perspective, intergrating both behavioral measures and individual perceptions to capture the true well-being of the older adults.⁹

One notable finding in this study was that sleep behavior showed a significant association with quality of life (p = 0.005). Poor sleep has long been associated with diminished cognitive function, mood disorders, and lower life satisfaction among older adults. Although approximately 70% of the participants reported “fair” sleep quality, differences in sleep patterns were still associated with variations in QoL among participants. This suggests that even minor disturbances in sleep may be associated with meaningful reductions in perceived well-being. Tucker et al emphasized through a systematic review and meta-analysis that poor nutritional status and poor sleep were both linked with reduced QoL in institutionalized older adults, reinforcing the role of fundamental daily behaviors in shaping long-term well-being.¹⁰ Similarly, Tatineny et al underscored that sleep architecture changed with age and was often accompanied by insomnia, fragmented sleep, and increased sleep latency, all of which contributed to daytime dysfunction.¹¹ These disruptions can lead to irritability, fatigue, cognitive decline, and social withdrawal, thus deteriorating QoL. Furthermore, Gothe et al found that sleep quality was closely linked with physical activity and psychosocial well-being.¹² Their findings suggest that better sleep is associated with more consistent physical activity, fewer depressive symptoms, and stronger social support factors that, collectively, predicted higher QoL in community-dwelling older adults.

Contrary to expectations, this study found no significant association between medication adherence and QoL ( p = 0.491), although a substantial proportion of participants were categorized as non-adherence to medication. One possible explanation is the structured nature of medication administration in institutional settings, where the standardized delivery of prescribed drugs reduces the variability typically caused by individual adherence behaviors. This finding also underscores the multifactorial complexity of chronic illness management among older adults, suggesting that pharmacological treatment alone may not be sufficient to enhance overall well-being. Psychosocial aspects, environmental support, and the burden of comorbidities may play a more prominent role in shaping QoL than adherence in isolation. Therefore, interventions aimed at improving QoL among older adults should adopt a holistic approach that integrates medical, psychological, and social dimensions rather than focusing solely on medication compliance. Nutritional intake also did not show a significant relationship with QoL (p = 0.445), despite the majority of participants reporting adequate food intake. While nutrition remains essential for physical health, Tucker et al found that its effects on QoL may have been moderated by the emotional context of mealtimes and individual autonomy in food choices.¹⁰ In institutional settings where food provision is standardized, limited choice and reduced emotional engagement with meals may attenuate the impact on subjective well-being.

Sleep quality again emerged as a significant factor associated of QoL among older adults. A study by Almondes et al comparing pre-pandemic and pandemic sleep patterns among older adults reported that disruptions in sleep habits were associated with increased anxiety and reduced social interaction, which were linked to lower QoL scores.¹³ These findings reinforce the notion that psychological and environmental stability play a critical role in maintaining sleep quality and, by extension, life satisfaction in later adulthood. In contrast, disease prevention behavior and physical activity were also not significantly associated with QoL in this study, possibly due to age-related functional limitations and fear of injury. Physical activity among the older adults often declines as a result of mobility limitations or chronic pain, which may prevent it from translating into perceived improvements in life quality unless accompanied by a sense of autonomy and psychological well-being.¹⁴

In addition, a cross-sectional study found that poor sleep quality was significantly associated with reduced QoL in retired older adults, particularly in domains related to emotional role functioning and general health perception.¹⁵ Other findings highlight the critical role of sleep as a determinant of both physical and psychological well-being in later life.¹⁶ Sleep disturbances may contribute to fatigue and impaired cognitive function but may also be associated with heightened anxiety, depressive symptoms, and social withdrawal, all of which negatively affect QoL. These findings suggests that interventions targeting sleep quality, such as sleep hygiene education, relaxation techniques, or supportive environmental modifications may indirectly enhance broader aspects of life satisfaction and health-related outcomes among older adults.

Given the demonstrated relationship between sleep and QoL, improving sleep behavior may represent an important consideration in geriatric care planning. Simple, non-pharmacological interventions such as sleep hygiene education, optimizing light and noise levels in care environments, and the establishment of individualized bedtime routines have been shown to be associated with improvements in sleep outcomes in institutional settings.¹⁷ Beyond their potential clinical benefits, such approaches are cost-effective and minimally invasive, making them particularly suitable for implementation in resource-limited social care institutions. Incorporating sleep-focused programs into routine geriatric care not only addresses sleep disturbances directly but also has the potential to indirectly enhance emotional well-being, cognitive function, and overall QoL in older adults. This study further highlights the need for a paradigm shift in evaluation and promotion of quality of life in institutionalized older populations. Moving beyond traditional health metrics, a more holistic approach should integrate psychological comfort and environmental tranquillity, in which sleep quality may acts as a important mediator. Future studies may explore how sleep-focused interventions interact with other domains such as emotional well-being, daily functioning, and cognitive functioning to enhance QoL in later life.

Several limitations of this study should be acknowledged. First, the cross-sectional design precludes causal inference, and the observed associations should be interpreted with caution. Second, although quality of life was measured using a validated instrument, several health-related behaviors, including sleep quality, nutritional intake, and disease prevention activities were assessed using self-reported descriptive measures, which may be subject to reporting bias. Third, the highly imbalanced distribution of QoL categories may have limited statistical power and affected the robustness of the bivariate analyses. Finally, as the study was conducted in a single social care center among institutionalized older adults with mild to moderate dependency, the findings may not be generalizable to community-dwelling older adults or to other sociocultural contexts.

Conclusion

This study identified sleep behavior as the only statistically significant associated with quality of life among older adults residing in a social care center. Although the majority of participants demonstrated adequate medication adherence, nutritional intake, disease prevention behavior, and physical activity, these factors were not significantly associated with overall QoL. This finding suggests that subjective dimensions particularly those related to rest and psychological well-being, may play a more prominent role in shaping perceived quality of life in late adulthood than objective health behaviors alone.

The findings are consistent with international evidence, including a meta-analysis by Sella et al. (2023), which highlighted sleep quality as an important factors associated with emotional, psychological, and functional well-being among older adults. In institutional settings, where autonomy and environmental control may be limited, suboptimal sleep quality sleep may further intensity fatigue, emotional distress, and reduced life satisfaction.

From a practical perspective, the result suggest that integrate sleep-focused strategies, such as sleep hygiene education, optimization of night time environments, and individualized bedtime schedules. Future studies employing longitudinal or interventional design are needed to further examine how improvements in sleep quality interact with psychological and functional domains to enhance QoL. Overall, addressing sleep quality may represent a feasible and cost-effective approach to supporting well-being among aging populations, particularly those living in intuitional care settings.