ANZ J. Surg. 2007; 77: 883–885 doi: 10.1111/j.1445-2197.2007.04265.

ORIGINAL ARTICLE

THE EFFECT OF AGE ON THE QUALITY OF LIFE OF PATIENTS LIVING

WITH STOMAS: A PILOT STUDY

NORMAN MA,* JAMIE HARVEY,* JOANNA STEWART,† LORRAINE ANDREWS* AND ANDREW G. HILL*
*Department of Surgery and †School of Population Health, University of Auckland, Auckland, New Zealand

Background: The formation of a stoma is associated with important effects on quality of life (QOL). The objective of this
prospective pilot study was to assess the effect of age on QOL after stoma formation.
Methods: Forty-nine patients requiring stoma formation had their QOL assessed by completion of the SF-36 v2 (SF-36v-1999
QualityMetric, Inc.) QOL questionnaire at three time points (preoperatively, at 6 months and at 12 months postoperatively).
Results: There was evidence of a difference in mental function according to age (P = 0.05) with younger patients continuing to
improve in QOL to 12 months, whereas older patients started higher but any improvement in their QOL over time was too small to be
shown. Physical function of QOL improved over time in both younger and older patients, but the pattern of change differed. Older
patients started higher but reached their maximum QOL by 6 months, whereas younger patients continued to improve. There was also
evidence of a difference related to presentation with acute presentations starting lower in terms of QOL than elective presentations
and showing an increase in QOL at both 6 and 12 months. No difference in change in QOL could be shown for type of stoma, sex or
reversal.
Conclusions: There was evidence that age and presentation are factors that influence changes in the QOL of stoma patients. Studies
have shown that a stoma nurse specialist may help to increase QOL. Therefore, stoma therapy should be targeted at older patients who
require more physical and mental support in adjusting to life with a stoma.

Key words: colorectal surgery, quality of life, stoma, stoma nurse specialist.
Abbreviation: QOL, quality of life.

INTRODUCTION of age on a patient’s mental and physical health in patients under-

going formation of an intestinal stoma.
The formation of a permanent or temporary intestinal stoma is
often necessary after colorectal surgery. Undergoing surgery and
having to live with a stoma have significant effect on a patient’s
mental and physical health.
METHODS
Many studies have shown a decrease in quality of life (QOL) in Patients and method
patients with a stoma. Contributions to this decrease in QOL
This study was prospective thus, enabling patients with stomas to
include dissatisfaction with preoperative preparation for surgery,
act as their own controls in assessing the effect of time on their
postoperative physical symptomatology, stoma-related complica-
QOL. The study was designed as a pilot study as the information
tions, a past psychiatric history and the presence of negative
required for a power analysis were not available for our popula-
stoma-related thoughts and beliefs.1 In addition, the diagnosis
tion. With ethical approval from the Northern Regional Ethics
of cancer and cancer death association also contribute to the
Committee and the Counties Manukau District Health Board
patient’s overall mental state.2 A Hungarian study of 100 colo-
Clinical Board, patients requiring stoma formation at Middlemore
stomy patients showed that 60 of these patients considered suicide
Hospital in 2003 and 2004 were approached preoperatively by the
at least once.3 Stomas are often placed in elderly patients, and it
colorectal nurse and consent obtained for participation. The study
has been our impression that some of these patients do not do well
assessed QOL, with participants completing a QOL questionnaire
with a stoma. However, the affect of age on QOL after stoma
at three time points (preoperatively, at 6 months and at 12 months
formation is not well characterized.
postoperatively). All patients were marked for a stoma preopera-
Thus, there are a number of influences on QOL that has been
tively by an experienced nurse. Elective surgery was carried out
identified, but the effect of age on QOL remains to be clarified.
by three colorectal surgeons and emergency surgery by the gen-
Thus, the objective of this prospective study is to assess the effect
eral surgeon on call.
N. Ma MBChB; J. Harvey BHB; J. Stewart PhD; L. Andrews RN;
A. G. Hill MD, FRACS. SF-36 v2 questionnaire
Correspondence: Associate Professor Andrew G. Hill, Department of Sur- The SF-36 v2 (SF-36v-1999 QualityMetric, Inc.) questionnaire is a
gery, University of Auckland, Middlemore Hospital, PO Box 93311, Otahuhu, generic QOL instrument that is not age, disease or treatment spe-
Auckland 1640, New Zealand.
Email: ahill@middlemore.co.nz
cific, making it ideal for application in this study on stoma pa-
tients with different underlying diseases and ages. The SF-36 form
Accepted for publication 16 January 2007. is a well-validated tool in assessing QOL, used in nearly 4000

2007 Royal Australasian College of Surgeons
884 MA ET AL.

publications, and has consistently been used to assess changes in
QOL over time.4 The questionnaire is divided into physical and
mental health, measuring eight health domains: (i) physical func-
tioning, (ii) role limitations as a result of physical health prob-
lems, (iii) bodily pain, (iv) general health, (v) vitality (energy/
fatigue), (vi) social functioning, (vii) role limitations as a result of
emotional problems and (viii) mental health. The measurements
are standardized using a linear T score transformation, and scores
are compared with the general US population who have a mean of
50 and standard deviation of 10.
Statistical analysis
To investigate the change in SF-36 scores from preoperation to
12 months postoperation, and factors that influenced this, a mixed
linear model was fitted with an unstructured correlation matrix for
within-subject observations. The SF-36 score was the outcome
and time (preoperatively, 6 months postoperation or 12 months
postoperation), age, sex, presentation (acute or elective), type of
stoma (ileostomy or colostomy) and reversal by 12 months were
the explanatory variables – the interaction of the other variables
with time was also investigated to see if the change over time was
influenced by any of the explanatory variables. Mental and phys-
ical scores were analysed separately.
RESULTS
higher, but any improvement with time was too small to be shown
(Fig. 1). There was also evidence of difference in presentation
(P = 0.03) with acute presentations starting lower in terms of
QOL than elective presentations. Acute presenters (n = 17) had
an increase in QOL at both 6 and 12 months, whereas elective
presenters (n = 32) had increased QOL at 6 months but no further
at 12 months. No difference in change could be shown for the
type of stoma (P = 0.39), sex (P = 0.55) or reversal (P = 0.58).
Physical health
The only variable that could be shown to be related to change over
time was age (P = 0.02), with both younger and older patients
improving in QOL over time (Fig. 2). The older patients began
higher and reached their maximum QOL by 6 months, whereas
younger patients had improved further to 12 months. The type of
stoma (P = 0.97), sex (P = 0.84), presentation (P = 0.30) or
reversal (P = 0.69) did not influence QOL.
DISCUSSION
The objective of this prospective study was to assess the effect
of age on mental and physical health after stoma formation.
The impact of age on mental function of QOL of stoma patients.
55
SF-36v2 quality of life score

A total of 49 patients participated aged between 23 and 86 years 50

(median age 64 years). Table 1 shows the number of patients in
different groups. Thirty-two patients were elective, whereas 17 45
were acute presentations. A total of 27 patients were men and 22
patients were women (male : female ratio, 1.2:1). Twenty-two 40
of the patients received a colostomy, whereas 27 received an
ileostomy. The reason for stoma formation included cancer 35
(26 patients), diverticular disease (7 patients), Crohn’s disease
(5 patients), ulcerative colitis (9 patients) and other (2 patients). 30
Eighteen underwent reversal of their stoma within the study period. Preoperatively 6months 12months
Time (months)

Mental health
There was evidence of a difference in change over time with age
(P = 0.05) with younger patients (<70) continuing to improve in
QOL to 12 months, whereas the older patients (‡70) began
Fig. 1. The change over time with age (P = 0.05) with younger
patients (<70) continuing to improve in QOL to 12 months, whereas
the older patients (‡70) began higher but had less improvement in
their QOL over 12 months. , ‡70; , <70.

Table 1. The number of patients <70 or ‡70 represented in terms of The impact of age on physical function of QOL of stoma patients.
time period (initial, 6 months and 12 months), sex, presentation, type 55
of stoma and reversal/non-reversal within study period
SF-36v2 quality of life score

Age (years) Total no. of 50

<70 ‡70 patients

45
(n = 35) (n = 14)

Initial, n (%) 35 (71) 14 (29) 49 (100) 40

6 months, n (%) 30 (71) 12 (29) 42 (86)
12 months, n (%) 24 (69) 11 (31) 35 (71) 35
Men, n (%) 18 (67) 9 (33) 27 (55)
Women, n (%) 17 (77) 5 (23) 22 (45) 30
Preoperatively 6months 12months
Elective, n (%) 21 (66) 11 (34) 32 (65)
Time (months)
Acute, n (%) 14 (82) 3 (18) 17 (35)
Colostomy, n (%) 16 (73) 6 (27) 22 (45)
Ileostomy, n (%) 19 (70) 8 (30) 27 (55) Fig. 2. Change over time with age (P = 0.02) with both younger
Reversal, n (%) 13 (72) 5 (28) 18 (37) and older patients improved in QOL over time. The older patients
Non-reversal, n (%) 22 (71) 9 (29) 31 (63) began higher and reached their maximum QOL by 6 months.
, ‡70; , <70.

2007 Royal Australasian College of Surgeons
EFFECT OF AGE ON PATIENTS WITH STOMAS
The findings from this study show that age is a factor that influ-
ences the QOL of stoma patients. In terms of mental functioning,
there was evidence of a difference in change over time with age
with younger patients continuing to improve in QOL to
12 months, whereas the older patients started higher but had less
improvement in their QOL over 12 months. Physical function
related to change over time with age showed that both younger
and older patients improved in QOL over time. However, older
patients started higher and reached their maximum QOL by
6 months.
Few studies have looked at age as a factor influencing the QOL
of patients after stoma formation. An Italian study used a self-
administered questionnaire to assess systemic symptoms, bowel
symptoms, functional impairment, social impairment and emo-
tional impairment of 34 patients with ileostomies. It did not show
a significant difference between age groups other than older
patients, requiring more assistance with their stomas.5 A study by
Stryker et al. looking at patients requiring ileostomy showed that in
all categories dealing with QOL, the group of older patients fared as
well or better than those younger than 60 years of age (67% of
respondents were over 60 years of age). Older persons, however,
reported greater difficulty in daily management of stomas. Occu-
pational and activity restrictions, however, were no more prevalent
in older patients than in their younger counterparts.6
There were improvements in QOL in both the mental and
physical function of stoma patients from preoperative to
6 months. This is consistent with many other studies. A large
European study assessing QOL in patients postoperatively after
stoma surgery found that QOL improved over time with a signifi-
cant difference seen between the postoperative and 3-month
scores.7
In the present study, there was also evidence of difference in
presentation with acute presentation starting lower in terms of
QOL than elective presentation but with both groups of patients
increasing in QOL with time. There was a longer effect in patients
with an acute presentation. There have been no studies to date
looking at presentation as a variable on effects of QOL over time.
There are a number of possibilities for these findings. Presumably,
patients get used to their stoma over time and develop coping
strategies. Acute patients have less time to come to terms with
the possibility of a stoma preoperatively and have less time with
a stoma nurse before receiving a stoma. In many cases, a formal
stoma nurse consultation is not available out of hours.
This study did not show any difference in QOL over change in
time for type of stoma, sex or reversal. However, this study was
not designed to detect differences related to these variables, and it
is very possible that these are important variables. A study by
Gooszen et al. showed no relationship between stoma type and
the degree of social restriction.8 In two separate studies, a differ-
ence in QOL between men and women has been shown, with
women showing a decreased QOL with a stoma.5,9
In 1961, Turnbull trained the first stoma therapist, Norma Gill,
and proposed stoma therapy as a new discipline.10 Since then, it has
been shown that patients with a stoma-care nurse have lower pres-
ent state examination scores than patients without these specialty
nurses.11 The primary role of the stoma therapist is to inform and
prepare patients and partners preoperatively for a possible stoma
and to maintain close contact with the patients postoperatively.12,13
It has been shown that specialized counselling of patients and
stoma therapy carried out by the stoma department contribute to
a significant improvement in QOL.14,15 Stoma therapists contrib-
ute to a rise in QOL most likely by increasing the patient’s con-

2007 Royal Australasian College of Surgeons
885
fidence with changing of stomal appliance, mentally preparing
them for the operation, knowledge of possible complications
and personally addressing any concerns the patient has involving
stoma and/or procedure.7 Therefore, an emphasis on preoperative
counselling and decreasing social restriction by providing emo-
tional support may help to increase QOL preoperatively and post-
operatively and decrease complications.
The objective of this prospective study was to assess the effect
of age on QOL after formation of a stoma. This pilot study sug-
gests that age is a factor that influences the QOL of stoma
patients. Older patients were shown to have less improvement
in their QOL over time in both mental and physical functioning
as compared with younger patients, with no improvement after
6 months although their preoperative QOL scores were not as low.
The findings of this study, if confirmed in larger prospective
studies, are important because, if true, preoperative and postop-
erative stoma care should be targeted at older patients who require
increased physical and mental support in adjusting to life with
a stoma, especially in the emergency setting.
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