Quality of Life in Multiple Sclerosis Patients: Influence of Gender, Age and Marital Status.

Background: Multiple sclerosis (MS) is a chronic disease characterised by a wide range of symptoms and a highly unpredictable prognosis, which can severely affect patient quality of life. Objective: The aim of the study was to evaluate the influence of gender, age and marital status on health-related quality of life (HRQoL) in MS patients.
Methods: This study included 100 MS patients treated at the Department of Neurology, Clinical Center University of Sarajevo. Inclusion criteria were an Expanded Disability Status Scale score between 1.0 and 6.5, age between 18 and 65 years, stable disease on enrollment. HRQOL was evaluated by the Multiple Sclerosis Quality of Life-54 questionnaire (MSQoL-54). Mann-Whitney and Kruskal-Wallis test were used for comparisons. Linear regression analyses were performed to evaluate prediction value of gender, age and marital status on both physical and mental HRQOL.
Results: Women had significantly lower QOL scores then men in pain scale (55.00 vs. 76.67; p<0, 05). Younger patients had better physical (54.58 vs. 37.90; p<0.05) and mental health (59.55 vs. 45.90; p<0.05) composite scores. Patients with earlier age of onset scored significantly higher in health perception domain scale (45.00 vs. 32.50, p<0.05). Married patinets scored higher in physical and mental composite scores but with no significant difference except in sexual function (87,51 vs 70, 86, p<0,05) and emotional well being (66,67 vs 33,33; p<0,05) scales. Patient age retined its independent predictivity of physical health composite score (r2=0.063).
Conclusion: Aging in MS proved to be important negative factor in predicting physical domains of QOL. Interventions for reducing difficulties caused by physical limitations in older patients, higher level of psychological support for patients with late onset disease and social support for those living alone are important factors in improving HRQOL in MS patients.

BACKGROUND

Multiple sclerosis (MS) is a chronic neurodegenerative condition characterised by a wide range of symptoms and a highly unpredictable prognosis, which can severely affect patient quality of life (QOL) (1). Many studies show that persons with MS have lower QOL even when comparing with persons with other chronic diseases such as epilepsy and diabetes mellitus (2). While physical disability is well recognized in MS patients, it does not necessarily reflect all aspects which patients should consider as important once in their life (3). Besides physical dysability, emotional and psychological status, lower QOL in MS patients can also be influenced by some sociodemographic factors. The findings show the importance of clinical, psychosocial and demographic variables as QoL risk and protective factors (4). Due to different hormonal states, social and family roles, the impact of MS is different between women and men. The risk for development of multiple sclerosis became higher in women than in men (2.3– 3.5:1) during the last decades, with true increase among the women but not the men (5). This rapid increase probably reflects unidentified changes in the environment or nutrition, while the effects of gender on clinical features of MS are not as clear (6). Still, studies show that female patients have better outcome of the disease by having earlier disease onset, slightly lower prevalence of primary progressive disease course and less progression of disability than men (6, 7). On the other side, depression, as the most favorable predictor of lower QOL in MS patients, is more common in women considering general population (8-10). Although it has been found that persons with MS has shorter lifespan than age- and sex-matched persons from general population, most of the MS patients is getting old with MS (11). The average age and life expectancy of persons with multiple sclerosis have increased significantly during the last two decades (12). The average age of persons with multiple sclerosis is rising according to large administrative databases (13). The introduction of disease-modifying therapies and a better delineation and understanding of the superimposed comorbidities often diagnosed in MS patients are probably the most important factors accountable for the increase in aging MS population worldwide (14). Older MS patients have more significant physical and cognitive limitations, mobility difficulties and social isolation issues than younger patients. Ageing is also accompanied by more comorbidities, medications use and other changes in life styles that can influence different aspects of QOL in persons with MS. Since the diagnosis of multiple sclerosis and unpredictive course of the disease can be devastating, social support might have important role in everyday activities and quality of life in MS patients. Support is defined as resources received due to interactions with other people (15). There are three types of resources identified in the context of support such as emotional support (attention, understanding of patients’ emotions and most of all, promoting their self-esteem), informative support (an advice helping patients to understand their medical problems, etiology and management) and the practical support which provides patients with physical and financial help and help necessary for specific activities (16). The previous research has suggested that there is a significant positive correlation between marital status, with HRQoL in patients with chronic diseases (17, 18). Married patients have reported better sexual function than that of patients who were unmarried (17). Married persons with multiple sclerosis or those living with partner showed to have better QOL then single persons with MS only in the relationships with friends, relationships with health care system and sentimental and sexual lifes domains (19). Using QoL measures may provide clinicians with the information regarding the general health status of MS patients who might otherwise go unrecognized with high recommendations for using them in clinical practice (20). MS patients QoL is often measured by the Multiple Sclerosis Quality of Life (MSQoL)-54 questionnaire, which is considered to be the most common and standardized disease-specific instrument for the assessment of QoL of MS patients (21). Since large numbers of worldwide studies that investigate HRQOL in MS patients still show some inconsistencies of findings, careful assessment is needed. The results of this study are expected to provide more information in planning and implementing interventions to increase MS patients’ QoL.

OBJECTIVE

The aim of the study was to evaluate the influence of gender, age and marital status on health-related quality of life (HRQoL) in MS patients at different stage of the disease.

PATIENTS AND METHODS

Participants

In this independent, observational, cross-sectional study 100 consecutive patients with multiple sclerosis treated at the Department of Neurology, Clinical Center University of Sarajevo, Bosnia and Herzegovina were included. Inclusion criteria for the study were: clinically defined diagnosis of MS according to previously published recommendations (26), Expanded Disability Status Scale (EDSS) score between 1.0 and 6.5 (27), 18 years of age or older and the patients which were able to give written informed consent. Exclusion criteria were cognitive deterioration (Mini Mental Status Test Score <26) (28), and the presence of any acute somatic or neurological disease.

Procedure and ethical considerations

The Ethics Committee of the Clinical Center University of Sarajevo gave ethical consent to perform the study after evaluating protocol. Each patient gave informed written consent to use the results obtained for publication before enrollment.

Measures

Patients reported their QoL using a self-administered questionnaire. The disease-specific Multiple Sclerosis Quality of Life-54 (MSQoL-54) questionnaire developed by Vickrey et al. was used (21); it has been translated and adapted to the Bosnian language (22). This questionnaire consists of 18 MS-specific dimensions and ratings for overall QoL (MS-18 module), in addition to the generic QoL features of the Short-Form 36-Item Health Survey Questionnaire (SF-36) (30) to obtain the MSQoL in reference to the following domains: physical health composite score (PHCS), mental health composite score (MHCS), physical function (PF), role limitation-physical (RP), emotional wellbeing (EWB), mental health (MH), role limitation-emotional (RE), bodily pain (BP), energy (EN), health perception (HP), social function (SF), change in health (CH), health distress (HD), cognitive function (CF), sexual function (SxF), satisfaction with sexual function (SSxF), and overall quality of life (QoL). The MSQoL-54 item results are transformed linearly to 0-100 scores, and final scores are calculated by averaging items within the scales.

Statistical analysis

Statistical analyses were performed for patients satisfying all the inclusion criteria. Demographic parameters and other baseline characteristics have been summarized. The Linkert method was adopted to assemble MSQoL-54 scale scores and the raw scores were transformed into 0-100 scales. Mann-Witney and Kruskal Wallis tests were used for comparisons between sociodemographic and clinical characteristics and QOL scores. Linear regression analyses were performed to evaluate prediction value of clinical and sociodemographic characteristics in predicting MSQOL-54 physical and mental composite scores, with a significance level of p<0.05.

RESULTS

Out of 69 (69%) of patients in this study were females. The mean age of patients at enrolment was 39.88+/- 10.03 years. Patient age groups are presented in Table 1. The mean age of patients at disease onset was 30.39+/-8.48 years , where 48 (48 %) of patients were younger then 30 years. The majority of patients in this study were married 64 (64%), 31 (31%) were single, 4 patients were widowed and 1 divorsed patient. 72 (72%) had relapsing-remitting MS, 25 (25%) had secondary progressive type while only 3 (3%) of patients had primary progressive type of disease. The mean EDSS score of all patients at enrolment was 3.57+/-1.73. Women had significantly lower QOL scores then men only in pain scale (55.00 vs. 76.67; p<0,05). Younger patients had statistical significant higher median value both of physical health composite score (54.58 vs. 37.90; p<0.05) and mental health composite score (59.55 vs. 45.90; p<0.05) comparing to older patients (Table 2). Patients with earlier age of onset (<30 years ) scored significantly higher only in health perception domain scale (45.00 vs. 32.50, p<0.05). Married patients scored higher then single patients (unmaried, widowed, divorced) in both PHCS and MHSC but with no statistical significant difference except in sexual function (87,51 vs 70, 86, p<0,05) and emotional well being (66,67 vs 33,33; p<0,05) scales (Figure 1). Patient age showed its independent predictivity of physical health composite score (r2=0.063) but not the mental health composite score. Gender, age of onset and marital status did not show indepent predictivity either of physical or mental health composite scores.

Table 1.

Patient age at the time of investigation (N=100)

Patient age (years)	Number of patients	U%
18-24	4	4
25-34	29	29
35-44	31	31
45-54	26	26
>55	10	10
Total	100	100

Table 2.

Multiple Sclerosis Quality of Life questionnaire (MSQOL)-54 scores according to patient age. * Multiple Sclerosis Quality of Life questionnaire-54

MSQQOL-54*domain	Median value of physical health composite score(25th-75th percentile)		P
	Age <45 years (n=64)	Age⩾45 (n=36)
Physical function	55.00 (30.00-78.75)	22.50 (15.00-53.75)	<0.001
Role limitations-physical	25.00 (0.00-93.75)	0.00 (0.00-0.00)	<0.001
Role limitations emotional	66.67 (0.00-100.00)	33.33 (0.00-66.67)	0.016
Pain	68.33 (40.00-92.92)	59.17 (31.67-76.67)	NS
Emotional well-being	64.00 (48.00-76.00)	60.00 (44.00-67.00)	NS
Energy	56.00 (40.00-64.00)	46.00 (32.00-56.00)	0.007
Health perceptions	47.50 (26.25-65.00)	30.00 (15.00-40.00)	<0.001
Social function	66.67 (41.67-83.33)	45.83 (25.00-58.33)	0.008
Cognitive function	75.00 (65.00-90.00)	62.50 (50.00-80.00)	0.005
Health distress	60.00 (30.00-78.75)	47.50 (22.50-68.75)	0.076
Overall quality of life	55.00 (45.00-68.35)	50.00 (36.65-58.35)	0.010
Sexual function	91.68 (58.28-100.00)	58.28 (33.00-79.19)	<0.001
Satisfaction with sexual function	50.00 (50.00-75.00)	50.00 (25.00-50.00)	0.019
Change in health	25.00 (25.00-50.00)	25.00 (0.00-50.00)	NS
Physical health composite score	54.85 (33.34-73.49)	37.90 (27.15-45.65)	0.002
Mental health composite score	59.55 (42.51-81.75)	45.90 (37.24-67.16)	0.007

Figure 1.

Physical and mental health composite scores MSQOL-54 * according to marital status * Multiple Sclerosis Quality of Life questionnaire-54

DISCUSSION

There were no significant differences in physical and mental health QOL composite scores between women and men in this study. These results are consistent with findings in many studies (23-26). On the other side, one study showed that male sex was related to poorer QOL in MS patients (27). Another study also reported lower scores of QOL in men but only in the physical QOL dimensions (28). Additionally, physical disability showed higher impact on quality of life in men than women, especially on mental HRQOL (29). Still, there is a study suggested that male gender is among contributing factors for better HRQOL (30). Our study also showed that women had significantly lower QOL scores then men in pain domain scale. This finding might be explained by different pain thresholds between women and men caused by different genetics, environmental and psychosocial factors, taking into account that pain is one of the important predictive factors of HRQOL. It is concluded that a higher degree of female social roles were associated with lower thresholds and less tolerance to pain, as well as a greater natural tendency to communicate pain sensation (31). Women also consider men, in general, to be more tolerant to pain, less willing to report pain, and less sensitive to it (32). The results are in accordance to conclusions that men and women have different responses to pain and increased pain sensitivity and risk for clinical pain was commonly observed among women (33). Although the causative factors underlying these sex differences are still not known, it seems that multiple biological and psychosocial processes are contributing factors (34). Evidences suggest that genotype and endogenous opioid functioning play a causal role in the sex differences, indicating that sex hormones influence pain sensitivity (35). The results of this study showed that younger persons with MS had better both physical and mental HRQOL which are similar to those in other studies (24, 30, 36-40). This study also showed that the most significant difference in QOL between younger and older MS patients was mostly in physical domains such as physical function, role limitations-physical, sexual function and health perception. On the other side, difference in emotional well-being subscale considering age was not significant. These results indicate that lower QOL in older MS patients is mostly influenced by limitations caused by physical disability, while emotional limitations are less presented probably due to development of positive copying mechanisms and adaptation to the disease as it progresses over time. The similar results were presented in recent study which showed that age had a direct relationship with mental HRQOL, and mental HRQOL increased by 0.64 with each passing year of patients with MS, while physical QOL showed a decrease by 0.24 for every 1 year (41). These results were explained by possible decreased life expectations with aging. Neurological impairment and physical disability, as indicators of the age-associated increase in physical impairment, were identified as risk factors for QoL in MS (42). Sonya Slifka study results found that although most people live alone over the age of 65 years they view their health with a positive outlook, and so they tend to adapt more over time as the disease progresses (43). Lower educational level and at least one comorbid condition of middle-aged and older people compared with younger people is found to have negative influence on physical HRQOL in one study (44). Urinary disorders are related to poorer QOL especially among older MS patients (45). According to one study, mental HRQOL increases in women and decreases in men as they get older (46). Our results showed that patient age was independent predictive factor of physical but not mental HRQOL, which is in accordance to the results of other studies indicating importance of developing coping strategies and emotional well being in MS patients in order to improve their QOL. Patients with earlier age of onset scored significantly higher in health perception domain scale in our study. These results might be explained by better adaptation to the health related problems and overall life expectations in patients with earlier onset of disease. One study showed better both physical and mental health composit scores in patients with onset of the disease in earlier age (28). The results might be also observed within the facts that patients with disease onset at older age are at higher risk for initial development of primary progressive disease type, sooner conversion to secundary progressive MS and reaching higer disability over shorter period of time. Married patients in our study scored higher then single patients (unmaried, widowed, divorced) in both physical and mental health composite scores , but signifficant difference was observed only in sexual function and emotional well being domains. Being married also showed to be predictor of better QOL in some studies (27, 40). These findings could be explained in accordance to the results of other studies that proved positive relation of social support, participation and individual’s psychological resources such as self-esteem and self-compassion with QOL (47-49).

CONCLUSION

Aging in MS proved to be important negative factor in predicting physical domains of QOL, while earlier age of onset showed positive influence on health perception in MS patients. Considering gender, only presence of pain showed significant impact on QOL with lower scores in women. Married patinets had better physical and mental composite scores but with no significant difference except in sexual function and emotional well being.

Interventions for reducing difficulties caused by physical limitations in older patients, higher level of psychological support for patients with late onset disease and social support for those living alone are important factors in improving HRQOL in MS patients.