Qual Life Res
DOI 10.1007/s11136-017-1593-6
Lifetime traumatic events, health-related quality of life,
and satisfaction with life in older adults
Catherine Lamoureux-Lamarche1,2 • Helen-Maria Vasiliadis1,2
Accepted: 5 May 2017
Ó Springer International Publishing Switzerland 2017
Abstract
Purposes The aims were to assess the association between
lifetime traumatic events and post-traumatic stress syn-
drome (PTSS) and health-related quality of life (HRQOL)
and satisfaction with life stratified by gender among a
community-dwelling sample of older adults.
Methods Data used came from the ESA-Services study
(2011–2013) and included a large convenience sample of
1811 older adults. Traumatic events were measured using a
list of 14 events. PTSS was measured using the Impact of
Event Scale-Revised. HRQOL and life satisfaction were
measured with the EQ-5D-3L and the Satisfaction With
Life Scale. Multivariate regression analyses were used to
assess the association between traumatic events, PTSS, and
quality of life.
Results Respondents had a mean age of 73.90 years (SD:
6.13, range 65–97). Our results showed that exposure to
violence (OR 4.88, CI 2.72–8.77), an accident (OR 2.33, CI
1.29–4.22), and sexual abuse (OR 2.26 CI 1.17–4.37) was
associated with PTSS only in women. No traumatic event was
associated only in men. The interaction between gender and
exposure to violence and life-threatening disease of a close
one was significant. Experiencing violence (b = -0.04,
& Catherine Lamoureux-Lamarche
catherine.lamoureux@usherbrooke.ca
Helen-Maria Vasiliadis
helen-maria.vasiliadis@usherbrooke.ca
1
Faculty of Medicine and Health Sciences, University of
Sherbrooke, 150 Place Charles-Le Moyne, Longueuil,
QC J4K 0A8, Canada
2 measurements are used in population studies assessing the
Research Centre, Charles-Le Moyne Hospital, 150 Place
Charles-Le Moyne, Bureau 200, Longueuil, QC J4K 0A8,
Canada
p \ 0.01), a natural disaster (b = -0.04, p = 0.02), a life-
threatening disease (b = -0.04, p \ 0.01), and sexual abuse
(b = -0.04, p \ 0.01) were associated with a lower HRQOL
only in women. No traumatic event was associated in men.
Interactions between event and gender were significant for
natural disaster, life-threatening disease of a close one, sexual
abuse, and other type of traumatic events. A life-threatening
disease (b = -0.90, p \ 0.01) was associated with a reduced
life satisfaction only in men and the exposure of violence
(b = -1.18, p \ 0.01) was associated with lower life satis-
faction in women.
Conclusion Our study could help healthcare professionals
to identify and monitor traumatic events that are at higher
risk to be associated with PTSS and a lower quality of life
for older men and women.
Keywords Traumatic event
Post-traumatic stress
syndrome
HRQOL
Life satisfaction
Older adults
Introduction
Post-traumatic stress disorder (PTSD) is a chronic disorder
that develops following a traumatic event such as exposure
to violence (war combat, armed robbery), natural disasters
(tsunami, flood, hurricane), injury and death (death of a
loved one, life-threatening illness). The Diagnostic and
Statistics Manual of Mental Disorder (DSM-IV) defined
PTSD as the experience of a traumatic event and the
presence of the following symptoms: intrusion, avoidance,
and hyperarousal [1]. The term post-traumatic stress syn-
drome (PTSS) has been previously used when self-reported
presence of PTSD-related symptoms in the absence of a
clinical evaluation [2, 3].
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The lifetime prevalence of traumatic events reported in
previous population-based studies of adults in developing
countries range between 69 and 80% [4–6]. In older adults,
studies have shown that 3–4.5% will fill the criteria for
lifetime PTSS or PTSD [7, 8]. Several researchers have
reported that some types of traumas are more likely to be
associated with PTSD symptoms [6, 9]. A general popu-
lation-based study of adults conducted in Germany repor-
ted that exposure to a serious accident, non-sexual assault,
combat or war zone, interpersonal conflicts, and life-
threatening illness was associated with a higher risk of
filling the criteria for full PTSS [10]. In Canada, adults who
had been badly beaten, experienced sexual assault, and
having witnessed someone killed or badly injured were
also more likely to report the presence of a lifetime PTSD
[6]. Pietrzak and colleagues (2012) similarly showed in an
older adult population that in reference to the worst trau-
matic event experienced, those reporting a serious or life-
threatening illness, other trauma to self, being beaten up by
an intimate partner, and sexual assault were more likely to
have full PTSD [7].
A reduced quality of life in older adults has been asso-
ciated with pain [11], depression [12, 13], multimorbidity
[14], and disability [15]. Kelley-Gillespie’s (2009) review
of the literature showed that the concept of quality of life in
older adults includes the following six domains: social
well-being, physical well-being, psychological well-being,
cognitive well-being, spiritual well-being, and environ-
mental well-being. According to this model, health-related
quality of life may be included in the physical well-being
domain and life satisfaction refers to the psychological
well-being domain [16]. Health-related quality of life
(HRQOL) was defined by Erickson and Patrick (1993) as:
‘‘The value assigned to the duration of life as modified by
the impairments, functional states, perceptions and social
opportunities that are influenced by disease, injury, treat-
ment or policy.’’ [17]. There are two types of health-related
quality of life instruments: ‘generic’ and ‘disease-specific’.
Most generic instruments were developed for healthy
populations or for populations with diverse illnesses, while
disease-specific instruments were developed for popula-
tions with specific diseases [18]. The concept of subjective
well-being is composed of three different components that
include life satisfaction, positive, and negative effects [19]
and can be described as ‘‘a global assessment of a person’s
quality of life according to his chosen criteria’’ [20].
Lower satisfaction with life has been reported among
older adults aged 65 years and over as compared to
younger adults in 2011 in a population-based Canadian
study [21]. An earlier study has shown gender differences
in HRQOL in adults living at home where up until age 74,
men report higher health-related quality of life than
women, after which this tendency is reversed, and women
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Qual Life Res
report higher HRQOL [22]. Canadian war veterans have
also shown lower scores on the SF-12 physical component
summary scale than the data observed in the general pop-
ulation [23]. This article also showed a significant positive
association between life satisfaction and health-related
quality of life [23]. Among young Canadian adults, a sig-
nificant negative association was reported between sexual
abuse and severe physical abuse and satisfaction with life
and scores on the SF-36 mental component summary scale
[24]. The study also reported that non-severe physical
abuse was also associated with lower life satisfaction [24].
Despite the fact that an association between PTSS or
PTSD and lower health-related quality of life and life
satisfaction has been reported [2, 25, 26], few studies have
assessed the association between trauma exposure and
quality of life. van Zelst et al. (2006) reported that the
presence of PTSD-related symptoms had similar conse-
quences on satisfaction with life, functional limitations,
and healthcare use as those with full PTSS [26]. A Cana-
dian study conducted among a representative sample of
adults in a catchment area of southwest Montreal reported
that respondents with either a current PTSD or those
exposed to trauma without PTSD had lower quality of life
compared to participants without trauma [27]. These find-
ings highlight the potential impact of traumatic events on
quality of life. To our knowledge there is no study to date
that has assessed the association between exposure to dif-
ferent types of traumatic events and quality of life in older
adults.
Given the increasing prevalence of potentially life-
threatening illnesses [28, 29] and older adult vulnerability
to violence [30, 31], the aim of this study was to assess the
association between lifetime traumatic events and PTSS
and health-related quality of life, as measured with the EQ-
5D-3L and satisfaction with life stratified by gender among
a community-dwelling sample of older adults consulting in
primary care practices. Based on previous reports sug-
gesting gender differences in the type of traumatic event
experienced and in the response (coping strategies, cogni-
tive function, symptom patterns) to such events [9, 32, 33],
we hypothesize gender differences in the types of traumatic
events associated with PTSS and quality of life.
Method
Data used came from the Étude sur la Santé des Aı̂nés
(ESA)-Services study, which was conducted in 2011–2013
and included a large convenience sample of older adults
(n = 1811). Participants were waiting to receive health
care services in one of the administrative regions of Que-
bec. The Health and Social Services Agency of this region
covers a population of 1,325,000 inhabitants.
Qual Life Res
First, physicians who practiced at least 4 days per week
in the administrative region selected for the study were
randomly selected from a registry and were invited to
recruit patients. General practitioners (GPs) were stratified
according to the type of primary health services clinics:
community health care center, family medicine group,
private clinics with less than three GPs, and private clinics
with three GPs or more. GPs first received a letter from the
Health and Social Services Agency covering the ESA-
Services Study region. The physicians then received a
second letter from the principal investigator of the ESA-
Services Study with the logo of the federal funding agency,
which explained the study objectives and recruitment
process of participants. If GPs accepted for their patients to
be recruited, the research coordinator went to the clinic to
place pamphlets and writing blocks with pens in the
waiting room and explained the study to the receptionist.
Clinic participation was voluntary and based on verbal
consent, physicians did not sign a consent form. Physicians
and receptionists could talk about the study to patients aged
65 years and over. A total of 744 physicians were eligible
for the study. From those, 409 accepted to participate in the
study and 245 clinics recruited patients aged 65 years and
over.
Procedure
Older patients aged 65 years and over who were consulting
in a clinic where a general practitioner accepted to par-
ticipate in the study received a pamphlet describing the
aims of the study in the waiting room. Patients who wanted
to participate had to leave a phone number where they
could be reached in the next month for a face-to-face
interview at home. Interviewers were health professionals
who received one-day training on the administration of the
ESA-Services questionnaire. A consent form was
explained and participants had to give their written consent
to begin the interview. The Mini Mental State Examination
(MMSE) [34] was also carried out at the beginning of the
interview to discriminate moderate and severe cognitive
impairment (MMSE \22). The face-to-face interview las-
ted on average 60–90 min and was conducted in an isolated
area of the house to minimize desirability bias. Consent
was also obtained from participants in order to access their
individual health services information from health admin-
istrative databases. Initially, 2745 patients gave their con-
tact information and 1811 completed the face-to-face
interview. The response rate was 66%. Preliminary analy-
ses comparing those who completed the at home interview
with those who did not, showed no significant difference
with respect to sex, psychological distress (10-items
Kessler Psychological Distress Scale [K-10]) [35], and
anxiety symptoms (7-items Generalized Anxiety Disorder
Scale [GAD-7]) [36]. The number of chronic diseases was
not available for those who did not complete the face-to-
face interview. Older adults who were too ill could have
been less likely to participate, and therefore our results may
have been underestimated by including healthier older
adults. We tried to limit this bias by conducting the inter-
view at home and rescheduling visits when needed. A
compensation of 15$ was given to participants for the
interview. The Ethics Committee of the University of
Sherbrooke’s Institute of Geriatrics and Charles-Le Moyne
Hospital Research Center approved the ESA-Services
study.
Measures
The presence of a lifetime traumatic event was measured
using a list of 14 traumatic events, which is similar to the
one used in DSM-IV criteria for PTSD [1]. An adapted
French-validated version of the Impact of Event Scale-
Revised (IES-R) was used to measure PTSS in the past
6 months [37] in reference to the worst traumatic event
reported. This scale is composed of 22 items on a Likert-
scale ranging from not at all to often. The IES-R questions
included intrusion, avoidance, and hyperarousal symptoms.
A previous study reported internal consistency coefficients
varying from 0.81 to 0.93 for the French version [37]. The
internal consistency (Cronbach’s alpha) in our sample was
0.94 for the total score. To our knowledge, no cut-point
was reported for older adult populations, but it was sug-
gested that this scale could be used to assess PTSS
symptoms among older adults [38]. For the purpose of this
study, a cut-off of 33, previously validated for community
populations, was used to identify PTSS cases [39]. We also
proceeded to group together some traumatic events that
were similar. The traumatic event ‘’war/combat’’ is defined
by the presence of one of the following events: exposure to
war, exposure to atrocities like mutilated bodies or mass
killing, being a refugee to avoid danger or persecution.
‘’Violence’’ was defined by the presence of one of the
following events: being beaten by a parent or a guardian or
witnessing physical violence, exposure to an armed rob-
bery or being threatened with a weapon, being victim of
violence or negligence by a spouse, one of your children or
someone from a person near you. Traumatic events that
had a low prevalence were grouped into the category
‘‘other’’ and included exposure to a toxic chemical product
or to a substance that can cause serious injury, being
stalked by someone, meaning being followed or watched in
a way that you felt in danger.
Quality of life was assessed from the patient and pop-
ulation perspectives using two instruments. The Satisfac-
tion With Life Scale (SWLS) was used to measure life
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 Qual Life Res

satisfaction [40], which represents the patient perspective. Results

The scale was adapted for older adults where the 7-point
Likert-Scale was reduced to 5 levels (completely disagreed The socio-demographic characteristics of the ESA-Services
to completely agreed). This scale included 5 questions with study sample (n = 1811) are presented in Table 1. Partic-
a total score ranging from 5 to 25. The French version of ipants had a mean age of 73.90 years (SD: 6.13, range
the SWLS has been validated among a French-Canadian 65–97). More than half of the sample were women
population [41]. The internal consistency coefficient (57.2%), were married/common-law union (63.0%) and
(Cronbach’s alpha) was 0.84 in our sample. had an annual household income of 25,000$ and over
To assess HRQOL, from a population perspective, mea- (62.7%). Twenty-six percent of respondents had primary
sures from the ESA-Services questionnaire were summa- education (26.1%). Participants had on average 3.75
rized to reconstitute the same questions found in the EQ-5D- chronic diseases (SD: 2.29, range 0–13). The prevalence of
3L, which includes five domains: mobility, self-care, usual post-traumatic stress syndrome was 5.5% in women and
activities, pain/discomfort, and anxiety/depression [42]. The 2.5% in men.
level of response ranged from 1 to 3 (no problem to extreme As presented in Table 2, women were more likely to
problems). Canadian weights were not available at the time experience violence (v2 = 4.63, p = 0.03) and sexual
of the study and we therefore used American weights to abuse (v2 = 22.49, p \ 0.01) than men, whereas men were
estimate utility scores [43]. Scores range from 0 to 1, where more exposed to combat (v2 = 13.71, p \ 0.01) and
1 represents perfect health and 0 represents death. accidents (v2 = 12.53, p \ 0.01) than women.
Other variables as potential confounders were also With regards to the association between the presence of
studied and included age, marital status, income, and a lifetime traumatic event and PTSS (Table 3), the gender-
number of chronic disorders. Age was measured as a specific analyses show that for both men and women, life-
continuous variable. Marital status was categorized as threatening disease of a close one was associated with the
married or single/divorced/widowed. Income was defined presence of PTSS. In women, exposure to violence (OR
by the gross annual household income and dichotomised 4.88; CI 2.72–8.77), an accident (OR 2.33; CI 1.29–4.22),
as \25,000$ and C25,000$. Finally, the number of chronic
disorders was measured using a list of 17 chronic diseases.
Table 1 Socio-demographic characteristics of the ESA-services
study sample (n = 1811)
Analyses
N %
V2 statistics were used to test for gender differences in the
Sex
prevalence of traumatic events. Multivariate logistic
Men 774 42.8
regressions were used to study the presence of PTSS as a
Women 1036 57.2
function of the presence of traumatic events. The coeffi-
Marital status
cients were estimated using the Maximum Likelihood
Married/common-law partner 1136 63.0
Estimation [44] and our logistic models converge well with
Single/divorced/widowed 667 37.0
non-significant Hosmer and Lemeshow test results, which
Education
suggested that our models fit well to the data. Multivariate
Primary 469 26.1
linear regressions were also carried out to test the associ-
Secondary/post-secondary/university 1325 73.9
ation between HRQOL and life satisfaction and the various
Household income
traumatic events. Interactions were also tested between
\25,000$ 541 37.3
type of event and gender. The analyses were also restricted
by gender and were controlled for potential confounding C25,000$ 908 62.7
factors: age, marital status, income, and number of chronic Means SD
disorders. SPSS 18.0 was used to conduct the analyses. We
Age 73.90 6.13
imputed socio-demographic variables used as control
Number of chronic disease 3.75 2.29
variables that had missing data (income, marital status)
using multiple imputations. At first, the following variables Women Men
were used for multiple imputations: age, sex, income, N (%) N (%)
marital status, education, and poverty index. After, a total Post-traumatic stress syndrome (PTSS)
of 10 complete datasets were produced with SAS version Yes 57 (5.5) 19 (2.5)
9.3 PROC GLM. The mean results of these datasets were
No 979 (94.5) 755 (97.5)
used to carry the multivariate analysis.

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Qual Life Res

Table 2 Gender differences in the type of traumatic events experi- natural disaster (p = 0.02), life-threatening disease of a
enced using v2 analysis close one (p = 0.03), sexual abuse (p = 0.03), and other
Women Men v2 p value type of traumatic event (p = 0.05). The results also
n = 989 n = 739 showed an association between satisfaction with life and
% sexual abuse for men and women. In men, a life-threat-
Combat/war 4.6 9.0 13.71 <0.01 ening disease (b = -0.90, p \ 0.01) was associated with a
Violence 27.0 22.5 4.63 0.03 lower life satisfaction. The exposure to violence was
Imprisonment 1.7 2.3 0.75 0.39 associated with a lower satisfaction with life in women
Serious accident 17.3 24.2 12.53 <0.01 (b = -1.18, p \ 0.01) (Table 5). Adjusted R2 ranged from
Natural disaster 8.1 9.0 0.44 0.51
0.05 to 0.07 for women and 0.08–0.09 for men. No inter-
Life-threatening disease 16.7 19.5 2.24 0.13
action between type of event and gender was significant for
life satisfaction.
Life-threatening disease of a 39.2 35.4 2.62 0.11
close one
Sexual abuse 13.0 6.1 22.49 <0.01
Other (exposure dangerous 9.9 12.4 2.83 0.09 Discussion
substance and being
stalked) This study reports on the HRQOL and life satisfaction
associated with the presence of lifetime traumatic events
and sexual abuse (OR 2.26; CI 1.17–4.37) was associated experienced by a large cohort of community-living older
with PTSS. In men, no traumatic event was associated with adults. Our results showed that men and women experi-
PTSS. Pseudo R2 ranged from 0.04 to 0.12 for women and enced different types of traumatic events. Men were more
0.12–0.24 for men. Interactions between type of traumatic likely to be exposed to war and accidents, which has
event and gender were significant for violence (p = 0.04) similarly been reported in a German population-based
and life-threatening disease of a close one (p = 0.05). study of older adults [8]. Women were more likely to have
Table 4 presents the gender-specific associations experienced sexual abuse than men, which concords with a
between traumatic events and HRQOL. In women, expe- Canadian study conducted among a general population of
riencing violence (b = -0.04, p \ 0.01), a natural disaster adults [6]. Another study however, including a general
(b = -0.04, p = 0.02), a life-threatening disease population of older adults, has not reported differences
(b = -0.04, p \ 0.01), and sexual abuse (b = -0.04; between men and women regarding sexual abuse [8]. This
p \ 0.01) were associated with a lower HRQOL. No difference might be attributed to the low frequencies (\5)
traumatic event was significantly associated with HRQOL of rape and childhood sexual abuse reported by men in this
in men. Adjusted R2 varied from 0.09 to 0.10 for women study that might lead to a diminished power to observe
and 0.11–0.12 for men. Interactions were significant for statistical significant results. Previous research among

Table 3 Gender-specific multivariate logistic analysis reporting the association between traumatic events and the presence of PTSS
Women Men
n = 985a n = 732a
Adjusted odds ratio (AOR)b Pseudo Adjusted odds ratio (AOR)b Pseudo
R2 R2

Combat/war 1.85 (0.68–5.00) 0.05 2.14 (0.59–7.81) 0.13

Violence 4.88 (2.72–8.77) 0.12 1.27 (0.45–3.53) 0.12
Imprisonment 1.66 (0.34–8.00) 0.04 4.13 (0.47–37.04) 0.13
Serious accident 2.33 (1.29–4.22) 0.06 0.98 (0.34–2.84) 0.12
Natural disaster 1.81 (0.81–4.02) 0.05 0.41 (0.05–3.33) 0.13
Life-threatening disease 1.38 (0.72–2.64) 0.04 1.79 (0.67–4.78) 0.13
Life-threatening disease of a close one 2.46 (1.41–4.29) 0.07 11.24 (3.13–40.00) 0.24
Sexual abuse 2.26 (1.17–4.37) 0.06 2.78 (0.79–9.80) 0.14
Other (exposure to dangerous substance and being stalked) 1.81 (0.87–3.75) 0.05 2.40 (0.84–6.85) 0.14
Results in bold are significant (p \ 0.05)
a
The sample size changed for each analysis. The sample size reported here is the lowest among all these analyses
b
Analyses were controlled for age, marital status, income, and number of chronic disorders

123
 Qual Life Res

Table 4 Gender-specific multivariate linear regressions reporting the association between traumatic events and health-related quality of life
(EQ-5D-3L)
Women Men
a
n = 959 n = 726a
Beta (B)b p-Value Adjusted R2 Beta (B)b p-Value Adjusted R2

Combat/war -0.05 [0.05 0.10 0.01 0.76 0.12

Violence -0.04 \0.01 0.10 -0.02 0.16 0.12
Imprisonment 0.03 0.52 0.09 -0.01 0.95 0.12
Serious accident -0.02 0.07 0.10 -0.01 0.74 0.12
Natural disaster -0.04 0.02 0.10 0.01 0.52 0.12
Life-threatening disease -0.04 \0.01 0.10 -0.01 0.69 0.12
Life-threatening disease of a close one -0.02 0.09 0.09 0.01 0.32 0.12
Sexual abuse -0.04 \0.01 0.10 0.01 0.75 0.11
Other (exposure to dangerous substance and being stalked) -0.03 0.11 0.09 0.01 0.44 0.12
Results in bold are significant (p \ 0.05)
a
The sample size changed for each analysis. The sample size reported here is the lowest among all these analyses
b
Analyses were controlled for age, marital status, income, and number of chronic disorders

Table 5 Gender-specific multivariate linear regressions reporting the association between traumatic events and life satisfaction (SWLS)
Women Men
a
n = 969 n = 731a
Beta (B)b p-Value Adjusted R2 Beta (B)b p-Value Adjusted R2

Combat/war -0.11 0.84 0.06 -0.54 0.17 0.09

Violence -1.18 \0.01 0.07 -0.45 0.11 0.09
Imprisonment 0.29 0.75 0.05 -0.62 0.41 0.08
Serious accident -0.23 0.45 0.06 -0.27 0.31 0.08
Natural disaster 0.12 0.78 0.06 -0.31 0.45 0.08
Life-threatening disease -0.18 0.58 0.06 -0.90 \0.01 0.09
Life-threatening disease of a close one -0.20 0.41 0.05 -0.36 0.14 0.09
Sexual abuse -1.48 \0.01 0.07 -1.01 0.04 0.09
Other (exposure to dangerous substance and being stalked) -0.43 0.27 0.06 -0.57 0.11 0.09
Results in bold are significant (p \ 0.05)
a
The sample size changed for each analysis. The sample size reported here is the lowest among all these analyses
b
Analyses were controlled for age, marital status, income, and number of chronic disorders

older adults also showed that men were more likely to
report exposure to violence than women, which is not
concordant with our results [8, 45]. The differing results
may in part be attributed to the use of different definitions
of the type of traumatic event experienced. For instance,
these previous German general population studies of older
adults included a high proportion of participants reporting
war and combat-related traumatic events, which was not
the case in our study.
While the prevalence of traumatic events experienced is
higher in men than women [32], many have shown that
women are more likely to report PTSD than men in general
populations [6, 7]. The results of our study showed gender
differences in the type of traumatic events associated with the
presence of PTSS. For women, exposure to violence, a seri-
ous accident, a life-threatening disease of a close one, and
sexual abuse was associated with the presence of PTSS. This
result is similar to previous research reporting that the
exposure to serious accident, non-sexual assault, and death of
a close one was associated with the presence of full PTSS in
women [10]. Our results, however, do not concord with those
reported by Lukascheck et al. (2013) where exposure to
combat or war and life-threatening disease was associated
with the presence of full PTSS in women [10]. We also
reported that women who experienced sexual abuse were
more likely to report PTSS. In contrast, this previous study
did not report any association between sexual assault and
abuse and full PTSS in women [10]. In our study, men

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Qual Life Res
exposed to life-threatening disease of a close one were more
likely to have PTSS. This result does not concord with by
Lukaschek et al. (2013) who reported that death of a close one
was not associated with full PTSS in men [10], which may in
part be due to the fact that they included a general population
of adults (n = 3080) aged between 32 and 81 years recruited
from population registries in Southern Germany.
Our results also showed gender differences in the type of
trauma that was associated with PTSS, which has similarly
been reported elsewhere [6, 10]. The frequency and severity
of these events might explain why women are at higher risk to
develop PTSD [32]. For example, in our study, women were
more likely than men to report violence and sexual abuse.
Many have suggested that different coping strategies [9],
cognitive functioning including pre- and peri-trauma experi-
ences and responses [9, 32, 33] may in part explain the gender
differences in the development of PTSD. Others have also
reported that women are more likely to be exposed to risk
factors associated with PTSS such as neuroticism, physical
anxiety sensitivity, depression, and peri-traumatic panic [46].
To our knowledge, this is the first study to assess the
association between types of traumatic events experienced
and HRQOL and satisfaction with life in older adults. In
women, the presence of a number of traumatic events was
associated with a lower HRQOL as measured by the EQ-
5D-3L such as being exposed to violence, a natural disas-
ter, a life-threatening disease, and sexual abuse. Others
have also reported that following life-threatening diseases
(coronary artery disease, renal graft loss), women are more
likely to report lower HRQOL than men [47, 48]. A study
conducted among Tunisia adults reported that the exposure
to violence was associated with a lower quality of life and
this association was more important in women [49]. A
review conducted by Tolin and Foa (2006) showed that
women were more likely to report depression and anxiety
symptoms following a traumatic event, which might also
have an effect on HRQOL [32]. In our study, no traumatic
event was associated with a lower HRQOL among men.
Regarding life satisfaction, for both men and women, the
presence of sexual abuse was associated with lower life
satisfaction. Experiencing a life-threatening disease was
associated with lower life satisfaction in men. This was
similarly reported in a study focusing on a population of
stoke survivors, where men reported lower satisfaction with
life than women [50]. In women, exposure to violence was
associated with lower life satisfaction. Similarly, a previous
study conducted among women found that domestic vio-
lence was associated with lower life satisfaction [51].
Given the differences observed, future studies are nee-
ded to better understand the gender differences in the
association between type of traumatic events and health-
related quality of life and life satisfaction and to identify
factors that might explain these differences.
The results reported in this study may be subject to some
limitations. First, compared to older adults aged 65 years
and over from the 2006 and 2011 census and provincial
socio-demographic information, participants from the
ESA-Service study (n = 1811) were younger (62.5% aged
65–74 years vs. 55.4% in Quebec), lived with a partner
(63.0 vs. 55.2% in Quebec), had a higher household
income (62.7% C25,000$ vs. 40.3% in Quebec), and had
higher education (73.9% secondary/post-sec/university vs.
52.6% in Quebec) [52–55]. Percentages were similar
regarding gender [52]. Our findings may be generalized to
a subgroup of older adults aged 65 years and over living at
home who were younger, lived with a partner, and had
higher household income and education and were using
primary health care services in a public-managed health-
care system. However, a convenience sample was used in
our study and the generalization of our results is limited for
other samples of older adults. Second, we had missing data
in our study and this decreased the sample size of our
multivariate analyses, which might suggest selection bias.
We compared participants with and without missing data
on the EQ-5D-3L and the SWLS, and they were similar
regarding exposure to traumatic events. However, partici-
pants with missing data on the SWLS were more likely to
be exposed to war/combat, and older adults with missing
data on the EQ-5D-3L were more likely to be exposed to
other type of traumatic events. This suggests that our
results may be underestimating true associations. The
causal relationship between traumatic events and PTSS and
quality of life could not be assessed because of the cross-
sectional nature of the data. Although the presence of
lifetime traumatic events was assessed in the study of more
recent quality of life, a number of unobservable variables
such as personality traits, may be important for the concept
[56]. Considering that our models explained between 5 and
12% of the variance of HRQOL and life satisfaction, future
studies should therefore focus on factors that might have an
important impact on these associations such as genetic
predisposition and coping skills as well as the presence of
daily life stressors. Lifetime traumatic events were mea-
sured, which may have been subject to recall bias. The IES-
R was measured in the last 6 months only. We were not
able to control for the length of time since the traumatic
event, the frequency, and the severity of these events.
Despite these limitations, our study was carried out in a
large population of older adults seeking care in primary care
in the province of Quebec. The ESA-Services study provided
data that allowed us to control for potential confounders. To
our knowledge, this is the first study assessing the associa-
tion between traumatic events and quality of life stratified by
gender. Results from our study showed that the presence of
life-threatening disease was associated with lower HRQOL
in women and lower satisfaction with life in men. Exposure
123

to violence was also associated with lower HRQOL and
satisfaction with life in women. Given the importance of
well-being for healthy aging, as underlined by the WHO [57]
and the increased prevalence of potentially life-threatening
chronic disease [28, 29] and older adults vulnerability to
violence [30, 31], health care professionals should pay closer
attention to at-risk individuals who are more likely to
experience these events, which can lead to lower HRQOL
and satisfaction with life. Studies have shown that reduced
QOL in older adults is associated with poorer health status
[14, 58] and psychological distress [12, 13, 59], which have
an impact on health system costs [60, 61].
Conclusion
Different types of traumatic events were associated with
PTSS and quality of life for men and women. Future
studies should focus on factors that might explain gender
differences in the association between traumatic events and
the presence of PTSS in older adults. Further, more studies
are also needed to better understand the moderating and
mediating factors between traumatic events and HRQOL
and life satisfaction for men and women.
Acknowledgements The authors thank Michel Préville, the PI of the
ESA-Services Study cycle 1. Dr. Préville devoted his career to the
mental health of older adults and was a pioneer in his field. He passed
away in March 2016. The authors also thank Djamal Berbiche, PhD.,
for statistical support.
Funding The ESA-Services Study cycle 1 was funded by the Fonds
de la Recherche Québec – Santé (FRQS) (Reference number: 16000).
Compliance with ethical standards
Conflict of interest Ms. Lamoureux-Lamarche was supported by a
graduate doctoral research scholarship from the Fonds de la Recherche
Québec—Santé (FRQS) in partnership with the Unite Soutien SRAP,
Québec. Dr. Vasiliadis was supported as a Senior Research Scientist of
the Fonds de la Recherche Québec—Santé (FRQS).
Ethical approval All procedures performed in studies involving
human participants were in accordance with the ethical standards of
the institutional and/or national research committee and with the 1964
Helsinki Declaration and its later amendments or comparable ethical
standards.
Informed consent Informed consent was obtained from all individ-
ual participants included in the study.
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