Abstract

Background

Vitality is often mentioned in the context of successful ageing, however, there is still no consensus on the definition of vitality. Moreover, older persons themselves have yet to be involved in establishing a definition of vitality.

Aim

To explore and describe how older persons define vitality, how they experience vitality, and what influences their vitality.

Method

A qualitative study consisting of 33 semi-structured interviews with community-dwelling older persons (60鈥�+) in the Netherlands. The interviews were analysed using the thematic content analysis.

Results

The definition of vitality that emerged from the interviews was 鈥渧itality is having the physical, cognitive, and social capacities to do what you want to do鈥�. The important dimensions of vitality can be divided into their capacities and their drivers in life. The capacities consisted of physical, cognitive, and social capacities. Sustaining these three capacities was important for the preservation of vitality. Main drivers in life were autonomy, independence, and meaning in life. Their experience of vitality was mostly determined by the balance between their capacities on one side and their drivers in life on the other side. Furthermore, this balance, and therefore their vitality, could be impacted by their lifestyle, loss of social network, coping, and role models.

Conclusion

According to older persons, vitality is determined by the balance between their capacities to do what they want to do on one side, and their drivers in life on the other side.

Introduction

Successful ageing has been a topic of research for years [1]. In essence, the discourse about successful aging can be divided into two types of perspectives: the biomedical perspective and the psychosocial perspective [2,3,4,5]. The biomedical perspective is predominantly based on quantitative data and research resulting in an outsider鈥檚 perspective on successful ageing. According to this perspective, successful aging means optimal physical, mental and social functioning. This optimal functioning can further be influenced by someone鈥檚 wellbeing [2, 4]. In contrast, Von Faber et al. [5] demonstrated that in the psychosocial perspective reaching a state of well-being is a central part of successful aging, rather than merely being an influencing factor. They showed that successful ageing is not determined by objectively measured physical functions, but by the subjective satisfaction of the individuals themselves with their adaptation to physical limitations. They found that when using a biomedical perspective only 13% of participants had optimal functioning and could therefore be considered to be aging successfully. However, it appeared that 45% of the same participants considered themselves to be aging successfully after applying the psychosocial perspective.

One of the elements that greatly contributes to successful aging is vitality [1,2,3, 5,6,7]. A common complaint experienced by older persons is a decrease in their vitality; this decrease is an indicator of aging-related decline [8]. Declining physical health is considered to be the main factor that negatively impacts their vitality [9]. Research in younger populations showed additionally that being female, younger, single, obese, having less exercise and having a lower annual income or being currently unemployed, increased the risk on impaired vitality [10]. Besides, physical health, emotional health, participation in meaningful activities, mastering new skills and roles, and support and recognition from others contributed to emotional vitality [11].

Despite vitality being important for successful aging, we found no consensus about its definition in the literature. In biomedical discourses, the term vitality was used in relation to the level of energy for the maintenance of optimal homeostasis [12,13,14]. Bautmans et al. [15] developed a consensual working definition for vitality capacity as 鈥榓 physiological state (due to normal or accelerated biological ageing processes) resulting from the interaction between multiple physiological systems, reflected in (the level of) energy and metabolism, neuromuscular function, and immune and stress response functions of the body鈥�. In this view, vitality can be captured with measurements of the balance in energy intake and expenditures [12]. Ryan and Frederick [16] however, defined subjective vitality from a psychosocial perspective as 鈥渢he conscious experience of possessing energy and aliveness鈥� which seems comparable with quantitatively measuring vitality with the 12-item short-form Health Survey (SF-12) [10, 17]. Westendorp and Schalkwijk [2] suggested operationalizing vitality as 鈥渢he ability of a person to set ambitions appropriate for one's life situation and being able to realize these goals鈥�.

To our knowledge older persons themselves have yet to be involved in establishing a definition of vitality and thereby providing an insider鈥檚 perspective. This insider鈥檚 perspective will reveal more insights in the meaning of vitality and the dynamics between the barriers and facilitators that play a role in vitality. Therefore, this study aims to explore and describe how older persons define and experience vitality, and what influences their vitality by conducting interviews with community-dwelling older persons.

Methods

Thirty-five qualitative face-to-face in-depth interviews were conducted with community-dwelling older persons in the Netherlands. These interviews were embedded in an educational program of the Master Health, Ageing and Society (formerly known as Vitality & Ageing) from the University of Leiden and the Leiden University Medical Center. The interviews were analysed with a thematic content analysis [18].

Recruitment strategy

The participants were recruited via the Older Persons Advisory Board for Care and Welfare South Holland region North and posters in and around the Leiden University Medical Center. Potential participants who were 60听years or older and who expressed an interest in taking part in this study received an information sheet. Since the research was embedded into an educational program, the participants were free to decide to take part in the interview just for educational purposes or for both educational and research purposes.

Data collection

35 students (29 female, 6 male) of the master鈥檚 Health, Ageing and Society cohort 2019鈥�2020 conducted individually a semi-structured interview in November 2019 for educational and research purposes. They were trained by experts in the field of qualitative research in carrying out interviews, making a topic list and using probing questions. The interviews took place at the participants鈥� homes, in the Leiden University Medical Center, or at another location chosen by the participant. One student postponed the interview till Spring 2020 and was forced to collect the data by phone due to COVID-19 restrictions.

The interview guide developed for the interviews consisted of two parts to explore the perspectives of older persons on vitality. For part one, the students asked four mandatory questions on vitality: (1) How do you define or describe vitality? (2) What are important aspects regarding vitality in daily life? (3) What things do you do to preserve your vitality? and (4) What are influencing factors regarding vitality? For the second part, the students chose their own topic(s) related to vitality in small groups of three or four students, and each group made a topic list to perform their interviews. In addition to the interviews, each interviewee completed a brief questionnaire regarding sex, age, living situation, living with a partner, daily functioning, number of medications and number of chronic illnesses). They also rated their social life, health, quality of life, and vitality from 1 to 10. These data were collected to be able to describe the characteristics of the participants.

Data analysis

The interview recordings were transcribed verbatim and anonymized. The transcripts were independently read and re-read multiple times to become familiarized with the data by two members of the research team (MJ and CW). Preliminary ideas for analysis were written in interpretive notes. Two researchers (MJ and CW) started by coding the common segments of ten interviews with mandatory questions inductively line-by-line. This process was carried out independently to increase reliability. Emerging themes were organized in an analytical framework for axial coding, which focused on the two analysis units of the research question (1. description of definition and experienced vitality, 2. description of influencing factors). This analytical framework was discussed within the research team until consensus was reached. Accordingly, researcher MJ coded the interviews completely and added new codes when this was considered necessary. The interviews were analysed using the software ATLAS.ti version 8.0. After coding, the data were sorted according to themes. The emerging themes were discussed in regular team meetings, resulting in an iterative process moving backwards and forwards between transcripts and the evolving findings. Themes were merged into one theme if they essentially described the same phenomenon or significantly overlapped in content. In the final stage of the analysis, the research team examined the relations between the themes. Quotations were selected to illustrate each theme. Excel Microsoft 365 was used for descriptive statistics on data from the brief quantitative questionnaire.

Respondent validation

To maximize validity, the findings of this study were presented in a meeting of the Older Persons Advisory Board for Care and Welfare South Holland region North. This advisory board aims to promote the quality of life of older persons by functioning as a competent partner in education, research, and policy development in the field of housing, welfare, and care for older persons. Their suggestion to compare the definition and the dimensions of vitality between men and women was taken into account and subsequently analysed further.

Results

A total of 35 interviews were conducted of which two were lost due to technical problems. This resulted in the inclusion of 33 participants, 10 men and 23 women. The participants were on average people with higher education, who were living in private homes, often with a partner, who had good daily functioning and did not requiring assistance, who were taking less than 4 medications, and who had no more than 1 chronic illness (Table听1). They all rated their own social life, health, quality of life, and vitality as at least adequate, with an average of 8 out of 10.

Table 1 Characteristics of study participants

Defining vitality

Based on the interviews, six dimensions could be identified that participants use to define vitality (Table听2). Participants described physical, cognitive and social capacities as dimensions of vitality. Next to these capacities, the participants described the importance of drivers in life for vitality. These drivers in life also encompassed three dimensions: independency, autonomy and meaning in life. When capacities decreased, it appeared that vitality could be retained by adjustment of the drivers. Furthermore, this balance, and therefore vitality, appeared to be impacted by lifestyle, loss of social network, coping, and role models.

Table 2 Overview of the definition, dimensions and influencing factors of vitality

This dynamic concept of vitality that emerged from the interviews was captured in the following definition: 鈥淰itality is having the physical, cognitive, and social capacities to do what you want to do鈥�. The definitions given by the participants ranged from a few keywords to an extensive explanation, as expressed by two interviewees:

A feeling of fitness that a person experiences depending on the mental and physical condition.听(Male, 77)

When I look at vitality, I think that it is wanting to get the most out of life as possible. And of course, that's different when you're 18, I'm almost 73, but it still is to get the most out of it, depending on all the circumstances. (Male, 72)

Capacities

The capacities of vitality consisted of physical capacities, cognitive capacities, and social capacities. Almost all of the participants mentioned physical capacities as an important dimension of their vitality. Their physical capacities could be negatively impacted by disabilities or (chronic) illnesses and bettered or restored by receiving medication and/or medical intervention. This especially applied for those that had to live with physical pain. Many participants experienced a fear of declining physical health but seemed to expect and accept a certain amount of (physical) decline with advancing age. They mentioned that the most important difference compared to when they were younger was that their health was no longer self-evident.

And then I find one of the most challenging aspects of ageing: health. (Female, 75).

Their cognitive capacities were another dimension of vitality. The respondents valued being able to understand what is happening around them in the world. They wanted to stay interested in the world around them and to discuss that with others. For some this meant participating in a social club that centred around the discussion of societal relevant topics. A few participants expressed that their cognitive capacities were more important than their physical capacities. One of the male respondents phrased it as follows:

If you cannot maintain it cognitively or mentally, what good is a very healthy body? Yes, I mean that will not bother you, but even then, you are unable to realize things. (Male, 75)

Their social capacities were another relevant dimension for their vitality. Being socially active and having social contacts gave them feelings of belonging and relevancy. Some felt their family connections, especially with children and grandchildren, were the most important social connections, while for others it was said to be less important. Some of them had many friends, while others enjoyed the occasional small talk with people when walking the dog and felt that was sufficient. Therefore, the quantity and quality that constituted a sufficient social life were dependent on their preferences. Even though all respondents rated their social life sufficient, some of them mentioned that this was not always the case. At moments when their social life felt insufficient, their vitality was negatively impacted, for example some mentioned experiencing loneliness and feeling socially isolated. A 71-year-old female respondent declared:

Of course, social contacts are also very important, right. To keep you participating in life. (Female, 71 years)

Some of the participants had had a partner that had passed away and they spoke about the effect of the loss of their partner on their life. To continue with their life after this impactful event, they indicated that they needed to take more initiative to meet people. Some of them also said that some relationships with other people had changed because of the loss of their partner and that they found that a difficult matter.

I also have a group with which we go cycling together. We have been doing this for four years. Four days that we cycle through the Netherlands and afterwards we meet at one of our places, and then yes, then all the wives are there. And I am the only one who is a widower. And those are sometimes from that moment when I think of raahhh. But yeah. (Male, 72)

Drivers in life

The drivers in life encompassed according to the older individuals three dimensions: autonomy, independence, and meaning in life. The participants often expressed the desire to experience minimal boundaries in life and when doing activities that they want to do. The concepts of autonomy and independence were therefore considered important drivers in life. For the participants, the feeling of autonomy was based on the ability to make decisions themselves and thereby having a sense of control. This could range from what they were going to eat for dinner to making major life decisions.

Keeping the control myself to stay as vital as possible for as long as possible. (Male, 70)

Their independence was mainly seen in being able to do things by themselves and not needing help from others. Especially mobility, in the broadest sense, was frequently mentioned. This included being able to drive a car, living on their own, going wherever and whenever they wanted to go from getting groceries to traveling to foreign places, and being able to walk and ride a bike. Feeling autonomous and independent gave a feeling of freedom, and if either their autonomy or their independence would decline, the participants expected that their vitality would be negatively affected.

When you become dependent on others, then, yes, you are less vital. (Male, 76).

Many participants mentioned the need to keep meaning in life and to feel useful after they had retired, so they could stay vital. They mainly found this in volunteering and that gave them a feeling of participating in society. Also helping others in need, like neighbours, gave them a feeling of usefulness. For the participants with grandchildren, this feeling of usefulness was also found in caring for their grandchildren and picking them up from school. Meaning in life was by some also found in setting goals in their life and having new ambitions to challenge themselves.

Yes, that you still have ambitions, that you want to go forward, yes. That you still set goals for yourself. (Female, 68)

Experience of vitality

Vitality was mostly judged by the balance between their capacities on one side and their drivers on the other side. When their capacities decreased and drivers could not complement the capacities anymore, vitality was likely to be rated lower. Adjustment of their drivers could then result in a higher experienced vitality, by restoring the balance.

And now we go on Saturdays, if we go, then we go for 60 or 80 kilometres. When we were younger that was 150 kilometres. [鈥�] Yes, that is for my age quite much if you ask me. (Male, 72)

In case of a temporary decrease in one of the capacities, participants also experienced a decrease in their vitality. For example, having a temporary physical disability could decrease vitality, but once it was cured, the experienced vitality was back at its original level. This showed that the experienced vitality was variable, especially when physical capacities were affected. This also indicated that vitality could differ over time.

We assume that things will always get worse. But we don鈥檛 consider that, indeed, with (鈥�) new hips, you can actually do much more again. (Female, 69).

Influencing factors on vitality

Four factors emerged from the interviews that impacted the capacities and drivers, namely lifestyle, loss of social network, coping, and role models.

Lifestyle

The participants stated that their lifestyle had a big impact on their physical health, and they found it important to preserve their physical and cognitive capacities. The recurrent components of lifestyle were physical activity, diet, smoking, and alcohol consumption. Many participants stated that they noticed that being physically active had a positive impact on their physical health. Tasks in and around the house stimulated being active as well, such as gardening. Particularly the participants that were less able to exercise attributed value to the tasks in and around the house; they saw them as easily accessible and plannable.

And I notice that when I go for a walk, walking briskly, that that is very good for my body. And that it puts you firmer on your legs. I am convinced, and I recently told a friend, that if I would not be physically active, I would need a walker within a year. I just feel that. (Female, 80)

Another important tool for maintaining their physical activity levels, and therefore their physical capacities, was the use of medical aids. Participants that needed the help of medical aids, like a walker, explained that these aids helped them to live a more active life and to do their daily tasks.

I can鈥檛 walk for half an hour without my walker because of my arthrosis. (Female, 88)

Many participants believed and experienced that eating a healthy and varied diet helped to maintain their physical health. They were also informed about the negative consequences smoking and alcohol can have on their health.

For that, you just have to keep moving, eat a bit healthy, not smoke -which I never did, we never did- so that鈥檚 not an issue. (Female, 69)

In order to maintain their cognitive capacities, the participants had several strategies. Reading was frequently mentioned, sometimes in the form of a reading club. Others made music, played bridge or had another strategy to challenge themselves cognitively. Many of them stated the urgency to stay up to date with news. They wanted to know what happened in the world and to understand it. Also staying up to date with technology was mentioned by many participants. They felt the need to adapt to the changing world and modern technology to keep participating in society.

What I find very important for myself is to stay digitally active. I push myself to do that. I see friends who have a partner, and when that partner becomes incapacitated, they can鈥檛 even do online banking. Well, you can鈥檛 afford that in this day and age. (Female, 80)

Loss of social network

Some of the participants talked about the loss of people in their social network and how that impacted their social life. They indicated that their social network had become smaller with getting older because of their retirement and people passing away, and that that had a big impact on their vitality. For some of them, the decrease in social contacts was an indication to invest in maintaining the relationships they had with their current people in their social network. Some of the participants also started to try to expand their social network to make up for the loss of their earlier social contacts that had passed away and to prevent possible loneliness in the future. They expanded their network for example with joining a new club or doing voluntary work.

I think you need to invest in your relationships at this moment. So, what I am now, in the sixty, seventy, beginning seventy years, you must invest in relationships. Because otherwise, it鈥檚 too late. You don鈥檛 have your work anymore, and you, if you are sitting at home and doing nothing. Its, its, then you lose your relationships. So, I, I really try to meet people to make appointments. To go have lunch with friends. That kind of things. (Female, 66)

Coping

According to the participants, becoming older comes with new challenges. Many of them acknowledged that it was likely that their health would decrease in the future and that they took this into account. Others chose not to worry about it too much and to deal with it when necessary. Some of the participants had not had physical complaints yet and were therefore not concerned about their future, while others had an intrinsic motivation to prevent physical complaints by living a healthy and active life. The ones with physical complaints showed willpower to push themselves and to focus on their possibilities. Some participants told that thinking positively was important for their vitality and helped them to deal with their challenges.

You have to be realistic, right. There will be some wear and tear here and there. Sure. But do you let that stop you? That is a different matter. (Female, 71 years)

For others it helped to look forward:

I mean even though you are 75, you can look back and see what has been, but I find it much more interesting to look at what is next. Even though there are no more 75 years coming, I understand that {laughs}. Uh. Yes, you do look at the years, the years that still exist. I, I think when you're 75, you do not have to look back on that was it and it is over. Because that is not how I live. (Male, 75)

Role models

Some participants knew real-life examples of older persons who had minimal physical decline and lived an active life. It showed them that it could also be possible for them. Even though they were aware that it was partly luck, it still provided clear motivation to stay active.

There are also older persons that I normally see every week, they are 89, 90, 91. They do not take part in the Olympic games anymore, but they have a clear mind, and they still do a lot. (Male, 75)

Some of the participants had or had had a person with dementia in their close environment and they expressed the fear to lose their cognitive abilities. It showed them that becoming older comes with vulnerability as well. They believed that being physically and cognitively active is a method to prevent or delay the onset of dementia.

They say that to prevent dementia, you should especially learn something new. I started learning Italian. (Female, 74)

Respondent validation

The findings of this study were taken back for respondent validation to the Older Persons Advisory Board for Care and Welfare South Holland region North. The invited members could identify themselves in the findings of the study. The definition of vitality and its dimensions seemed complete to them. Also, the influencing factors on vitality seemed logical to them, and they could also identify themselves on how they maintained their capacities. One of the members expected a difference in definitions and dimensions of vitality between men and women. However, subsequent analysis showed that in this study older men and women did not differ substantially regarding the way they defined or preserved vitality.

Discussion

The aim of this study was to explore how older persons define and experience vitality, and what influences their vitality. The overall definition of vitality that emerged from the interviews with older persons was 鈥榲itality is having the physical, cognitive, and social capacities to do what you want to do鈥�. The important dimensions of vitality can be divided into their capacities and their drivers in life. The capacities consisted of the dimension鈥檚 physical capacities, cognitive capacities, and their social capacities. Sustaining these three capacities was important for the preservation of vitality. Their drivers in life were composed of autonomy, independence, and meaning in life. Their feeling of vitality was mostly rated by the balance between their capacities on one side and their drivers in life on the other side. When capacities decreased, vitality could be retained by adjustment of the drivers. This balance, and thus their vitality, could further be impacted by coping, lifestyle, loss of social network, and role models.

Comparison with existing literature

When comparing our definition of vitality by older persons to the one of subjective vitality from Ryan and Frederick being 鈥渢he conscious experience of possessing energy and aliveness鈥� [16], important differences have to be noted. The first difference is that vitality in the Ryan and Frederick鈥檚 definition does not seem to be a continuum, but more a static state of being vital or not vital. Secondly, it does not take personal goals into account and lastly, autonomy and independence do not seem to fit into their definition. The beforementioned study by Westendorp and Schalkwijk [2] proposed to describe vitality as 鈥渢he ability of a person to set ambitions appropriate for one's life situation and being able to realize these goals鈥�. Our study illustrates that the definition of Westendorp and Schalkwijk is in line with the perceptions of older persons themselves. This definition also shows that someone can be vital despite experiencing limitations and reasons from what a person desires to do in life and, if someone can do that, he or she will feel vital.听Our study adds to the definition of Westendorp and Schalkwijk that, according to the participants in our study, the abilities of a person can be specified into physical, cognitive, and social capacities. This new insight is more related to the psychosocial perspective on successful ageing, which focused on the subjective satisfaction of the individuals themselves with their adaptation to physical limitations [5] than to the more outsider鈥檚 biomedical perspective on successful ageing.

Interestingly, our findings are also rather comparable with the conceptualisation of healthy ageing of the WHO as the 鈥榩rocess of developing and maintaining the functional ability that enables well-being in old age鈥� [19]. This refers to a balance between all individual's physical and mental capacities and their environment [20]. The ability of older people, however, to retain their experienced vitality by restoring the balance through adjustment of the drivers, is not clearly taken into account in the conceptual working definition of vitality capacity of the WHO [15], even though this definition also entails a dynamic process.

Strengths and limitations

Our study has several strengths. Firstly, as far as we know, this is the first study to examine the views and experiences of older persons on their vitality.听Second, we used semi-structured interviews, which allowed us to explore the perspectives of older persons on vitality in an in-depth manner [21]. Third, the sample size was sufficient for collecting older adults' perspective on vitality as it allowed us to analyse 33 interviews, after which data saturation was reached as no new themes emerged. Fourth, respondent validation was carried out: the outcomes of the study were presented to a group representing the interviewees.

Some limitations of the study have to be acknowledged as well. The interviews were performed by master students. Although these students were trained by experts, they were not experienced interviewers, which may have limited their abilities to keep on asking in-depth questions. An advantage of this approach is that the students were not familiar with the theories about vitality and therefore had an open mind going into the interviews. Another possible limitation of this study is that the older persons that participated in the study all rated their vitality as high. Older persons with low subjective vitality might have expressed a different experience of their vitality, and therefore, their narrative could have helped to compose a more complete picture of the perspectives on vitality. Exploring the perspectives of older persons with lower subjective vitality is recommended for future research.

Conclusion and implications for research

Older persons define vitality as 鈥渉aving the physical, cognitive, and social capacities to do what you want to do鈥�. Vitality is changeable and determined by the balance between their capacities on one side and their drivers in life on the other side. When these two sides of the balance correspond, vitality is regarded high. This balance can further be affected by lifestyle, loss of social network, coping and role models. It is recommended to further investigate how factors influencing this balance can be affected, to improve the experienced vitality of older persons.