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Age differences in the relationship between frailty and depression among community-dwelling older adults
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Age differences in the relationship between frailty and depression among community-dwelling older adults Lili Ji, PhDa, Xiaoxia Qiao, PhDa, Yaru Jin, PhDa, Huaxin Si, PhDa, Xinyi Liu, MScb, Cuili Wang, PhDa,* a b
School of Nursing, Peking University, 100191 Beijing, China School of Nursing, Shandong University, Jinan, China
A R T I C L E
I N F O
Article history: Received 15 November 2019 Received in revised form 28 January 2020 Accepted 31 January 2020 Available online xxx Keywords: Frailty Depression Older adults Age
A B S T R A C T
Objective: This study aims to examine age differences in the relationship between frailty and depression among older adults Methods: A total of 1789 community-dwelling older adults were recruited from eastern China. Physical frailty and depressive symptoms were assessed using the Frailty Phenotype and the 5-item Geriatric Depression Scale, respectively. Results: The hierarchical multiple linear regression analysis revealed that frailty was significantly related to depressive symptoms (b = 0.272, P < 0.001) and there was a significant interaction between age and frailty (b = 0.703, P < 0.001). The Johnson Neyman plot revealed that the relationship between frailty and depressive symptoms became weaker as people aged. Conclusions: Frailty is more likely to cause depressive symptoms among the young-old than among the oldold, reflecting the age-related positivity effect. This highlights that interventions on emotional regulation should particularly target the young-old to reduce the effect of frailty on depression. © 2020 Elsevier Inc. All rights reserved.
Introduction Depression is a common psychological problem with a chronic course and high relapse rate among older adults.1 3 It is associated with a range of deleterious outcomes such as lower well-being, higher use of healthcare services and increased morbidity and mortality,4,5 placing a great burden on patients and society. Physical frailty is another common clinical syndrome in older adults that carries outcomes similar to depression.6,7 The concept of frailty attempts to explain why older adults with the same chronological age vary widely in health and functional status, and is regarded as an important indicator for biological age.8 Frailty identifies individuals who need extra medical attention in the community and those who have greater risk of adverse health outcomes in clinical settings, and thus is an important criterion to implement early interventions for both social and clinical practitioners.8 The most well-known biological syndrome model of frailty is characterized by weight loss, exhaustion, inactivity, slowness, and weakness.9 Previous studies found the prevalence of physical frailty was 9.9% in
Financial support: This study was supported by the National Natural Science Foundation of China (grant number: NSFC 71673168). *Corresponding author. E-mail address: [email protected] (C. Wang). https://doi.org/10.1016/j.gerinurse.2020.01.021 0197-4572/$ see front matter © 2020 Elsevier Inc. All rights reserved.
community-dwelling older adults,8 33% in older medical inpatients10 and 46.9% in nursing home residents.11 An increasing number of studies have observed that physical frailty was associated with depression. And 16 35% of frail individuals experience co-existing depression.12 Previous large cohort studies have examined longitudinal associations between physical frailty and depressive symptoms and shown that physical frailty is significantly associated with incident depressive symptoms in older people.13 15 A recent meta-analysis has also shown that frailty is associated with an increased prevalence and incidence of depression.16 Although the role of frailty in predicting depression has been well documented, this relationship might be complicated by age, as negative affect appears to decrease steadily with increasing age in older adults.17 The older group is a broad group with high heterogeneity. Compared to the ‘young old’ (e.g. < 75 or 80 years old), older people in advanced old age (e.g. > 75 or 80 years old) often suffer from higher prevalence of disability.18,19 Specially related to the present study, the prevalence of frailty is higher in advanced age9 and the value of the frailty index increases exponentially with aging.20 Surprisingly, empirical evidence generally suggests that negative affect is relatively stable after the age 6021,22 or even decreases with increasing age.17 The absence of strong relationships between age and negative affect, despite an increment in risk and loss of physical functioning
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with advancing age, has been labeled a paradox.23 25 This ‘paradox’ effect might be attributable to that older people become more and more motivated to regulate their emotional experiences26 and have more effective coping mechanisms due to greater life experiences, maturity and self-esteem with advancing age.27 Further, older adults seem to be more likely to accept poor health (e.g. frailty) as a common event that accompanies aging,28 thus experiencing fewer negative affect from these stressful events. The moderating role of age between poor health and well-being has been reported in previous studies. One study29 on the relationship between disability and depressive symptoms in two old groups (< 80 vs. > 80) found that disability explained 12.8% of the variance in the depression score in the < 80 years old subject group, whereas this contribution decreased to 4.4% in the > 80 years old subject group. Another study30 on the association between frailty and life satisfaction in older adults found that frailty had a stronger negative impact on life satisfaction among the young-old (60 79 years) than among the old-old (80 + years). These results together suggested a protective effect of age on the reduction in older adults’ well-being due to poor physical health. Therefore, the present study aims to examine age differences in the relationship between frailty and depression among communitydwelling older adults. Depression is also associated with female sex, low educational and economic levels, living alone, suffering from chronic disease, pain, cognitive impairment, functional disability, poor self-rated health and less social support.31,32 The hypothesis is that the relationship between frailty and depression might become weaker with advancing age after controlling for these covariates. Methods Participants The data were collected from August 2015 to December 2016 in Jinan, Shandong Province, China. Participants were enrolled using a stratified sampling method, and details on sampling have been described elsewhere (blinded for review). Briefly, a total of 22 communities were included in the study. Community staffs coordinated the recruitment of older residents via putting up posters with relevant information about our study in the communities’ bulletin boards and distributing fliers to residents. Eligible participants were those aged 60 years or older who had no severe cognitive, visual or hearing impairment or serious physical deficits. Of the 2800 potential participants, 848 refused to participate, 35 were excluded for severe cognitive, visual or hearing problems or serious physical deficits. Finally, a total of 1917 participants were enrolled in the study. After signing the informed consent form, participants underwent face-to-face structured questionnaire interviews and physical performance assessments at the community center. The study was approved by the Institutional Review Board of the researchers’ university. Measures Physical frailty Physical frailty was the independent variable. Physical frailty was identified according to the Physical Frailty Phenotype, a widely used criterion developed by Fried, Tangen, Walston, Newman, Hirsch, Gottdiener, Seeman, Tracy, Kop, Burke.9 Frailty is defined as the presence of 3 or more of the following 5 components: weight loss, weakness, exhaustion, slowness, and low physical activity. The measurement of each component has been described in detail in our previous published work (blinded for review). In the present study, frailty was used as a continuous variable based on the number of components which met the criterion, with a score ranging from 0 to 5.
Depressive symptoms Depressive symptoms were the dependent variable. Depressive symptoms were assessed with the 5-item version of the Geriatric Depression Scale (GDS-5).33 The GDS-5 was created from the GDS-15 by selecting the 5 items with the highest correlation with the clinical diagnosis of depression, and was proved to be as effective as the 15item GDS.33 35 The total score ranges from 0 to 5, and 2 was considered to have clinically relevant depressive symptoms. Age and covariates Age was the moderate variable. And the following covariates were included into the analysis: gender, education, living arrangement (living alone or not), monthly income (< 3200 CNY or 3200 CNY), suffering from chronic disease (yes or no), pain (yes or no), cognitive impairment (yes or no), functional disability, self-rated health and social support. Chronic diseases included 12 common chronic diseases that have been found to be associated with depression in old age36: hypertension, diabetes mellitus, coronary heart disease, congestive heart failure, angina, myocardial infarction, stroke, arthritis, asthma, chronic obstructive pulmonary disease (COPD), chronic renal disease, and cancer. Participants were defined to be suffering from chronic disease if they self-reported to have been diagnosed one or more above diseases by physicians. Pain was measured using the revised Faces Pain Scale (FPS-R),37 and a score of 2 or greater indicates the presence of pain. The Short Portable Mental Status Questionnaire (SPMSQ)38 was used to assess cognitive function with above than 2 errors indicating cognitive impairment. The Katz Activities of Daily Living Scale (ADL) Index and Lawton Instrumental Activities of Daily Living Scale (IADL) were used to assess basic ADL and IADL,39,40 respectively, with lower scores indicating higher levels of physical function. Self-rated general health was measured using an item from the 12-item Short Form Health Survey (SF-12)41 ‘How would you rate your general health?’, and participants rated the item on a 5-point Likert scale ranging from 1 = ‘bad’ to 5 = ‘very good’. The Social Support Rating Scale (SSRS) was used to assess social support,42 with a higher score indicating more social support. The above scales have been widely used in Chinese older population, and have shown good reliability and validity. Statistical analysis The SPSS 25.0 was used to conduct data analyses. Sample characteristics were described using means (standard deviations) for continuous variables and frequencies (percentages) for categorical variables. We used independent sample t-tests for continuous variables and x2 tests for categorical variables to examine differences in the characteristics between participants with and without depressive symptoms. The hierarchical multiple linear regression models were performed to examine the relationship between frailty and depressive symptoms and its age differences. The covariates were entered in step 1, followed by the main effect terms (i.e., frailty and age) in step 2 and the product interaction term of frailty by age in step 3. The Johnson Neyman (J N) technique43 was used to plot the conditional effect of frailty on depressive symptoms across age to facilitate interpretation of a significant interaction. Results Of the 1917 participants enrolled in the study, 128 (6.7%) had missing values on frailty or depressive symptoms and were excluded from data analyses. The excluded sample did not differ from the remaining sample (n = 1789) in socio-demographic characteristics (age, gender, education, living arrangement, monthly income), medical variables (suffering from chronic disease, pain, cognitive
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impairment, functional disability), or psychosocial variables (selfrated health and social support). Table 1 shows characteristics for the whole sample and by depressive status. The participants had an average age of 69.16, and the majority were female (66.9%), living with their family (87.7%), having a low monthly income (70.1%), and suffering from chronic disease (83.1%). Of the participants, 39.0% reported the presence of pain and 5.8% had cognitive impairment. Participants with depressive symptoms were more likely to be female, living alone, having lower levels of education and monthly income, having less social support, suffering from chronic disease and pain, having poorer functional ability and self-rated health, and having higher frailty score. Table 2 shows the hierarchical multiple linear regression models examining the relationship between frailty and depression and its age differences. The model 1 showed that lower monthly income, pain, lower ADL and IADL score, poorer self-reported health and less social support were associated with depressive symptoms (total R2 = 0.184, F = 35.07, P < 0.001). With additional inclusion of age and frailty (Model 2), the variance in depressive symptoms that were explained by the full model increased to 0.247, and depressive symptoms were also associated with younger age (b = 0.167, P < 0.001) and frailty (b = 0.272, P < 0.001). With further inclusion of the age £ frailty interaction term (Model 3), the associations of depressive symptoms with age and frailty persisted and there was a significant interaction between age and frailty (b = 0.703, P < 0.001). The final full model explained 25.3% of the variance in depressive symptoms. The Johnson Neyman plot (Fig. 1) revealed that the relationship between frailty and depressive symptoms became weaker as participants aged. Discussion The present study extended previous findings by exploring age as a moderator in the relationship between frailty and depression. Consistent with the hypothesis, we found a protective effect of age on depressive symptoms associated with frailty, that is, frailty was less likely associated with depressive symptoms as people aged. This witnessed the ‘paradox’ effect in older adults,23 25 along with previous findings that disability was less related to depressive symptoms29
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Table 2 Hierarchical multiple linear regression models predicting depressive symptoms.
Variables Female Years of schooling Living alone High monthly income Suffering from chronic disease Pain Cognitive impairment ADL score IADL score Self-rated health Social support score Age in years Frailty score Age * Frailty Model fit
Model 1 b
Model 2 b
Model 3 b
0.028 0.013 0.012 0.048* 0.004 0.113*** 0.034 0.068** 0.119*** 0.199*** 0.224*** NA NA NA F = 35.07*** R2 = 0.184
0.027 0.038 0.006 0.005 0.006 0.089*** 0.025 0.051* 0.061* 0.151*** 0.210*** 0.167*** 0.272*** NA F = 72.83*** R2 = 0.247
0.028 0.040 0.005 0.001 0.002 0.089*** 0.026 0.049* 0.069* 0.149*** 0.210*** 0.108** 0.949*** 0.703** F = 11.53*** R2 = 0.253
NA, not applicable. * P < 0.05. ** P < 0.01. *** P < 0.001.
and frailty was less related to life satisfaction in the old-old group than in the young-old group.30 Some theories may help to explain this ‘paradox’ effect, that is, why older adults experience less depressive symptoms even though they become frailer with advancing age. Cartensen,44 for example, argued in the Socioemotional Selectivity Theory (SST) that the perception of time plays a fundamental role in the selection and pursuit of social goals. Younger people view the future as being largely open and are more likely to pursue knowledge-related goals, while older people view the future as being more bounded and thus emotional goals assume primacy in this group. With advancing age, older people will become more and more motivated to regulate their emotional experiences, i.e., to maximize positive affect and to minimize negative affect, as they realize that time is increasingly limited. Therefore, older adults with advancing age are more motivated to minimize the negative affect caused by frailty for their perception of limited time.
Table 1 Participants characteristics of the whole sample and by depressive status. variables Age in years Gender Years of schooling Living alone* Monthly income (CNY) a,** Suffering from chronic disease Pain*** Cognitive impairment**** ADL score IADL score Self-rated health Social support score Frailty score
male female yes no < 3200 3200 yes no yes no yes no
Total (n = 1789)
No depression (n = 1581)
Depression (n = 208)
69.16 § 6.64 592 (33.1%) 1197 (66.9%) 8.72 § 4.24 216 (12.1%) 1569 (87.7%) 1254 (70.1%) 496 (27.7%) 1286 (71.9%) 503 (28.1%) 697 (39.0%) 1085 (60.6%) 103 (5.8%) 1684 (94.1%) 11.82 § 0.53 15.39 § 1.59 2.64 § 0.93 37.99 § 7.05 0.65 § 0.88
69.19 § 6.67 537 (34.0%) 1044 (66.0%) 8.81 § 4.21 174 (11.0%) 1404 (89.0%) 1089 (70.6%) 453 (29.4%) 1110 (70.2%) 471 (29.8%) 571 (36.3%) 1003 (63.7%) 91 (5.8%) 1489 (94.2%) 11.85 § 0.49 15.49 § 1.43 2.73 § 0.91 38.60 § 6.79 0.55 § 0.78
68.86 § 6.37 55 (26.4%) 153 (73.6%) 8.03 § 4.41 42 (20.3%) 165 (79.7%) 165 (79.3%) 43 (20.7%) 176 (84.6%) 32 (15.4%) 126 (60.6%) 82 (39.4%) 12 (5.8%) 195 (94.2) 11.57 § 0.73 14.63 § 2.40 1.99 § 0.81 33.39 § 7.37 1.41 § 1.19
* 4 missing values. ** 39 missing values. *** 7 missing values. **** 2 missing values. a CNY, China Yuan. The median household per capita disposable income of Jinan City was CNY3200 ($US 498.44) per month in 2014.
t / x2
P
0.68 4.70
0.49 0.03
2.48 14.76
0.01 < 0.001
6.84
0.009
18.88
< 0.001
45.55
< 0.001
0 5.41 5.04 12.17 9.64 14.00
0.983 < 0.001 < 0.001 < 0.001 < 0.001 < 0.001
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Fig. 1. Johnson Neyman plot of the conditional effect of physical frailty on depressive symptoms across age. The abscissa axis and the vertical axis represent age and the effect of physical frailty on depressive symptoms, respectively. The solid line that slopes downward to the right shows that the effect of physical frailty on depressive symptoms gradually declines with advancing age.
The Model of Strength and Vulnerability Integration (SAVI) recognizes not only time left as posited by the SST, but also time lived as an important mechanism whereby people gain experience and practice when dealing with daily stressors.45,46 The Selection, Optimization, and Compensation with Emotion Regulation (SOC-ER) framework suggests that older adults select and optimize specific emotional regulation strategies to compensate for changes in available resources, and subsequently show enhanced ability in emotional regulation.47 The ‘old-old’ have more effective coping mechanisms due to greater life experience, maturity and self-esteem than the ‘young old’.27 Older adults have been found to have as many emotionally close social partners as, but fewer peripheral social partners than younger adults,48 thus constructing smaller but closer social networks associated with enhanced life satisfaction.49 In addition, compared with the young-old, old-old adults recall and recognize a higher proportion of positive relative to negative information,50 which may contribute to mood repairing. Older adults also tend to increasingly rely on cognitive reappraisal to cope with limited physical resources with advancing age,51,52 and greater use of positive reappraisal strategies has been found to predict better functional status specifically among old-old adults.52,53 Meanwhile, the old-old tend to prefer passive strategies, such as accepting the problem or suppressing their feelings,54 which have been found to be more useful when stressors are beyond control.55 Together, the enhanced ability in emotional regulation may contribute to buffer the detrimental effect of frailty on emotional well-being as people age, and thus the relationship between frailty and depressive symptoms becomes weaker with advancing age. Another explanation for this ‘paradox’ effect is the Aging Brain Model (ABM), suggesting that there are age-related changes in emotion-generative brain structures, such as the amygdala.56 According to the ABM, the amygdala activation in response to negative stimuli decreases with age, while amygdala activation to positive stimuli persists across age, which diminishes emotional arousal in response to negative stimuli, correspondingly reduces the memorial advantage of high arousal negative events and ultimately reduces negative affect.56 Therefore, being frail, though a negative stimuli, is often considered as rather normal,28,57 inducing lower emotional arousal and depressive symptoms among the old-old . Given that frailty is more related to depressive symptoms in the young-old, effective interventions should be established for this population to prevent, delay, or even reverse frailty to reduce its negative effect on emotional well-being. Previous studies have indicated the
efficacy of exercise-based and (or) nutrition supplementation interventions on physical frailty.58 60 Similar interventions are also needed for older adults with advancing age, although the negative impact of frailty among the old-old is weaker than among the youngold. Further, thoughts and behaviors that promote the ‘paradox’ effect—such as interacting more often with emotionally close social partners or deploying more attention or memory on positive information—can be taught to the young-old. For example, older adults that have 3 5 network members, a medium level of contact and a high level of emotional closeness are less likely to be depressed than their counterparts.61 Additionally, older adults showed great decreases in negative affect when asked to shift their attention away from an upsetting scene to their positive memory.62 Besides the above strategies that target one specific process of emotion regulation, the Problem Adaptation Therapy (PATH),41 which aims to improve all 5 processes of emotion regulation: situation selection, situation modification, attentional deployment, cognitive change and response modulation, might be more effective in promoting the ‘paradox’ effect among the young-old. The present study had some limitations. First, we could not make any causal inferences because the study utilized a cross-sectional design. Second, the study relied on self-report measures to assess some components of physical phenotype (such as loss of weight), which might have led to recall bias. Third, the participants were enrolled in one city of China. Generalizability of our findings to other areas of China and other cultural groups might not be warranted. Conclusions The current study is the first to examine age differences in the relationship between frailty and depression among communitydwelling older adults. The relationship between frailty and depression becomes weaker as people age. This highlights that effective interventions on emotion regulation aiming to promote ‘paradox’ effects should particularly target the young-old to reduce the detrimental effect of frailty on emotional well-being. References 1. Mitchell AJ, Hari S. Prognosis of depression in old age compared to middle age: a systematic review of comparative studies. Am J Psychiatry. 2005;162:1588–1601. 2. Mueller TI, Kohn R, Leventhal N, et al. The course of depression in elderly patients. Am J Geriat Psychiat. 2004;12:22–29. 3. Stek ML, Exel E, Van, Tilburg W, Van, Westendorp RGJ, Beekman ATF. The prognosis of depression in old age: outcome six to eight years after clinical treatment. Aging Ment Health. 2002;6:282–285. 4. Hare DL, Toukhsati SR, Peter J, Tiny J. Depression and cardiovascular disease: a clinical review. Eur Heart J. 2014;35:1365–1372. 5. Rodda J, Walker Z, Carter J. Depression in older adults. BMJ. 2011;343:683–687. 6. Clegg A, Young J, Iliffe S, Rikkert MO, Rockwood K. Frailty in elderly people. Lancet. 2013;381:752–762. 7. Woods NF, LaCroix AZ, Gray SL, et al. Frailty: emergence and consequences in women aged 65 and older in the women's health initiative observational study. J Am Geriat Soc. 2010;53:1321–1330. 8. Collard RM, Boter H, Schoevers RA, Oude Voshaar RC. Prevalence of frailty in community-dwelling older persons: a systematic review. J Am Geriatr Soc. 2012;60:1487–1492. 9. Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001;56:M146–M156. 10. Gingrich A, Volkert D, Kiesswetter E, et al. Prevalence and overlap of sarcopenia, frailty, cachexia and malnutrition in older medical inpatients. BMC Geriatr. 2019;19:120. 11. Kojima G. Prevalence of frailty in nursing homes: a systematic review and metaanalysis. J Am Med Dir Assoc. 2015;16:940–945. nchez CP, Garrido JF, Martínez RN, Ros VR, Cauli O. The relationship 12. Buigues C, Sa between depression and frailty syndrome: a systematic review. Aging Ment Health. 2015;19:762–772. 13. Collard RM, Comijs HC, Naarding P, et al. Frailty as a predictor of the incidence and course of depressed mood. J Am Med Dir Assoc. 2015;16:509–514. 14. Feng L. Frailty predicts new and persistent depressive symptoms among community-dwelling older adults: findings from Singapore longitudinal aging study. J Am Med Dir Assoc. 2014;15:76.e7–76.e12.
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Age differences in the relationship between frailty and depression among community-dwelling older adults Lili Ji, PhDa, Xiaoxia Qiao, PhDa, Yaru Jin, PhDa, Huaxin Si, PhDa, Xinyi Liu, MScb, Cuili Wang, PhDa,* a b
School of Nursing, Peking University, 100191 Beijing, China School of Nursing, Shandong University, Jinan, China
A R T I C L E
I N F O
Article history: Received 15 November 2019 Received in revised form 28 January 2020 Accepted 31 January 2020 Available online xxx Keywords: Frailty Depression Older adults Age
A B S T R A C T
Objective: This study aims to examine age differences in the relationship between frailty and depression among older adults Methods: A total of 1789 community-dwelling older adults were recruited from eastern China. Physical frailty and depressive symptoms were assessed using the Frailty Phenotype and the 5-item Geriatric Depression Scale, respectively. Results: The hierarchical multiple linear regression analysis revealed that frailty was significantly related to depressive symptoms (b = 0.272, P < 0.001) and there was a significant interaction between age and frailty (b = 0.703, P < 0.001). The Johnson Neyman plot revealed that the relationship between frailty and depressive symptoms became weaker as people aged. Conclusions: Frailty is more likely to cause depressive symptoms among the young-old than among the oldold, reflecting the age-related positivity effect. This highlights that interventions on emotional regulation should particularly target the young-old to reduce the effect of frailty on depression. © 2020 Elsevier Inc. All rights reserved.
Introduction Depression is a common psychological problem with a chronic course and high relapse rate among older adults.1 3 It is associated with a range of deleterious outcomes such as lower well-being, higher use of healthcare services and increased morbidity and mortality,4,5 placing a great burden on patients and society. Physical frailty is another common clinical syndrome in older adults that carries outcomes similar to depression.6,7 The concept of frailty attempts to explain why older adults with the same chronological age vary widely in health and functional status, and is regarded as an important indicator for biological age.8 Frailty identifies individuals who need extra medical attention in the community and those who have greater risk of adverse health outcomes in clinical settings, and thus is an important criterion to implement early interventions for both social and clinical practitioners.8 The most well-known biological syndrome model of frailty is characterized by weight loss, exhaustion, inactivity, slowness, and weakness.9 Previous studies found the prevalence of physical frailty was 9.9% in
Financial support: This study was supported by the National Natural Science Foundation of China (grant number: NSFC 71673168). *Corresponding author. E-mail address: [email protected] (C. Wang). https://doi.org/10.1016/j.gerinurse.2020.01.021 0197-4572/$ see front matter © 2020 Elsevier Inc. All rights reserved.
community-dwelling older adults,8 33% in older medical inpatients10 and 46.9% in nursing home residents.11 An increasing number of studies have observed that physical frailty was associated with depression. And 16 35% of frail individuals experience co-existing depression.12 Previous large cohort studies have examined longitudinal associations between physical frailty and depressive symptoms and shown that physical frailty is significantly associated with incident depressive symptoms in older people.13 15 A recent meta-analysis has also shown that frailty is associated with an increased prevalence and incidence of depression.16 Although the role of frailty in predicting depression has been well documented, this relationship might be complicated by age, as negative affect appears to decrease steadily with increasing age in older adults.17 The older group is a broad group with high heterogeneity. Compared to the ‘young old’ (e.g. < 75 or 80 years old), older people in advanced old age (e.g. > 75 or 80 years old) often suffer from higher prevalence of disability.18,19 Specially related to the present study, the prevalence of frailty is higher in advanced age9 and the value of the frailty index increases exponentially with aging.20 Surprisingly, empirical evidence generally suggests that negative affect is relatively stable after the age 6021,22 or even decreases with increasing age.17 The absence of strong relationships between age and negative affect, despite an increment in risk and loss of physical functioning
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with advancing age, has been labeled a paradox.23 25 This ‘paradox’ effect might be attributable to that older people become more and more motivated to regulate their emotional experiences26 and have more effective coping mechanisms due to greater life experiences, maturity and self-esteem with advancing age.27 Further, older adults seem to be more likely to accept poor health (e.g. frailty) as a common event that accompanies aging,28 thus experiencing fewer negative affect from these stressful events. The moderating role of age between poor health and well-being has been reported in previous studies. One study29 on the relationship between disability and depressive symptoms in two old groups (< 80 vs. > 80) found that disability explained 12.8% of the variance in the depression score in the < 80 years old subject group, whereas this contribution decreased to 4.4% in the > 80 years old subject group. Another study30 on the association between frailty and life satisfaction in older adults found that frailty had a stronger negative impact on life satisfaction among the young-old (60 79 years) than among the old-old (80 + years). These results together suggested a protective effect of age on the reduction in older adults’ well-being due to poor physical health. Therefore, the present study aims to examine age differences in the relationship between frailty and depression among communitydwelling older adults. Depression is also associated with female sex, low educational and economic levels, living alone, suffering from chronic disease, pain, cognitive impairment, functional disability, poor self-rated health and less social support.31,32 The hypothesis is that the relationship between frailty and depression might become weaker with advancing age after controlling for these covariates. Methods Participants The data were collected from August 2015 to December 2016 in Jinan, Shandong Province, China. Participants were enrolled using a stratified sampling method, and details on sampling have been described elsewhere (blinded for review). Briefly, a total of 22 communities were included in the study. Community staffs coordinated the recruitment of older residents via putting up posters with relevant information about our study in the communities’ bulletin boards and distributing fliers to residents. Eligible participants were those aged 60 years or older who had no severe cognitive, visual or hearing impairment or serious physical deficits. Of the 2800 potential participants, 848 refused to participate, 35 were excluded for severe cognitive, visual or hearing problems or serious physical deficits. Finally, a total of 1917 participants were enrolled in the study. After signing the informed consent form, participants underwent face-to-face structured questionnaire interviews and physical performance assessments at the community center. The study was approved by the Institutional Review Board of the researchers’ university. Measures Physical frailty Physical frailty was the independent variable. Physical frailty was identified according to the Physical Frailty Phenotype, a widely used criterion developed by Fried, Tangen, Walston, Newman, Hirsch, Gottdiener, Seeman, Tracy, Kop, Burke.9 Frailty is defined as the presence of 3 or more of the following 5 components: weight loss, weakness, exhaustion, slowness, and low physical activity. The measurement of each component has been described in detail in our previous published work (blinded for review). In the present study, frailty was used as a continuous variable based on the number of components which met the criterion, with a score ranging from 0 to 5.
Depressive symptoms Depressive symptoms were the dependent variable. Depressive symptoms were assessed with the 5-item version of the Geriatric Depression Scale (GDS-5).33 The GDS-5 was created from the GDS-15 by selecting the 5 items with the highest correlation with the clinical diagnosis of depression, and was proved to be as effective as the 15item GDS.33 35 The total score ranges from 0 to 5, and 2 was considered to have clinically relevant depressive symptoms. Age and covariates Age was the moderate variable. And the following covariates were included into the analysis: gender, education, living arrangement (living alone or not), monthly income (< 3200 CNY or 3200 CNY), suffering from chronic disease (yes or no), pain (yes or no), cognitive impairment (yes or no), functional disability, self-rated health and social support. Chronic diseases included 12 common chronic diseases that have been found to be associated with depression in old age36: hypertension, diabetes mellitus, coronary heart disease, congestive heart failure, angina, myocardial infarction, stroke, arthritis, asthma, chronic obstructive pulmonary disease (COPD), chronic renal disease, and cancer. Participants were defined to be suffering from chronic disease if they self-reported to have been diagnosed one or more above diseases by physicians. Pain was measured using the revised Faces Pain Scale (FPS-R),37 and a score of 2 or greater indicates the presence of pain. The Short Portable Mental Status Questionnaire (SPMSQ)38 was used to assess cognitive function with above than 2 errors indicating cognitive impairment. The Katz Activities of Daily Living Scale (ADL) Index and Lawton Instrumental Activities of Daily Living Scale (IADL) were used to assess basic ADL and IADL,39,40 respectively, with lower scores indicating higher levels of physical function. Self-rated general health was measured using an item from the 12-item Short Form Health Survey (SF-12)41 ‘How would you rate your general health?’, and participants rated the item on a 5-point Likert scale ranging from 1 = ‘bad’ to 5 = ‘very good’. The Social Support Rating Scale (SSRS) was used to assess social support,42 with a higher score indicating more social support. The above scales have been widely used in Chinese older population, and have shown good reliability and validity. Statistical analysis The SPSS 25.0 was used to conduct data analyses. Sample characteristics were described using means (standard deviations) for continuous variables and frequencies (percentages) for categorical variables. We used independent sample t-tests for continuous variables and x2 tests for categorical variables to examine differences in the characteristics between participants with and without depressive symptoms. The hierarchical multiple linear regression models were performed to examine the relationship between frailty and depressive symptoms and its age differences. The covariates were entered in step 1, followed by the main effect terms (i.e., frailty and age) in step 2 and the product interaction term of frailty by age in step 3. The Johnson Neyman (J N) technique43 was used to plot the conditional effect of frailty on depressive symptoms across age to facilitate interpretation of a significant interaction. Results Of the 1917 participants enrolled in the study, 128 (6.7%) had missing values on frailty or depressive symptoms and were excluded from data analyses. The excluded sample did not differ from the remaining sample (n = 1789) in socio-demographic characteristics (age, gender, education, living arrangement, monthly income), medical variables (suffering from chronic disease, pain, cognitive
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impairment, functional disability), or psychosocial variables (selfrated health and social support). Table 1 shows characteristics for the whole sample and by depressive status. The participants had an average age of 69.16, and the majority were female (66.9%), living with their family (87.7%), having a low monthly income (70.1%), and suffering from chronic disease (83.1%). Of the participants, 39.0% reported the presence of pain and 5.8% had cognitive impairment. Participants with depressive symptoms were more likely to be female, living alone, having lower levels of education and monthly income, having less social support, suffering from chronic disease and pain, having poorer functional ability and self-rated health, and having higher frailty score. Table 2 shows the hierarchical multiple linear regression models examining the relationship between frailty and depression and its age differences. The model 1 showed that lower monthly income, pain, lower ADL and IADL score, poorer self-reported health and less social support were associated with depressive symptoms (total R2 = 0.184, F = 35.07, P < 0.001). With additional inclusion of age and frailty (Model 2), the variance in depressive symptoms that were explained by the full model increased to 0.247, and depressive symptoms were also associated with younger age (b = 0.167, P < 0.001) and frailty (b = 0.272, P < 0.001). With further inclusion of the age £ frailty interaction term (Model 3), the associations of depressive symptoms with age and frailty persisted and there was a significant interaction between age and frailty (b = 0.703, P < 0.001). The final full model explained 25.3% of the variance in depressive symptoms. The Johnson Neyman plot (Fig. 1) revealed that the relationship between frailty and depressive symptoms became weaker as participants aged. Discussion The present study extended previous findings by exploring age as a moderator in the relationship between frailty and depression. Consistent with the hypothesis, we found a protective effect of age on depressive symptoms associated with frailty, that is, frailty was less likely associated with depressive symptoms as people aged. This witnessed the ‘paradox’ effect in older adults,23 25 along with previous findings that disability was less related to depressive symptoms29
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Table 2 Hierarchical multiple linear regression models predicting depressive symptoms.
Variables Female Years of schooling Living alone High monthly income Suffering from chronic disease Pain Cognitive impairment ADL score IADL score Self-rated health Social support score Age in years Frailty score Age * Frailty Model fit
Model 1 b
Model 2 b
Model 3 b
0.028 0.013 0.012 0.048* 0.004 0.113*** 0.034 0.068** 0.119*** 0.199*** 0.224*** NA NA NA F = 35.07*** R2 = 0.184
0.027 0.038 0.006 0.005 0.006 0.089*** 0.025 0.051* 0.061* 0.151*** 0.210*** 0.167*** 0.272*** NA F = 72.83*** R2 = 0.247
0.028 0.040 0.005 0.001 0.002 0.089*** 0.026 0.049* 0.069* 0.149*** 0.210*** 0.108** 0.949*** 0.703** F = 11.53*** R2 = 0.253
NA, not applicable. * P < 0.05. ** P < 0.01. *** P < 0.001.
and frailty was less related to life satisfaction in the old-old group than in the young-old group.30 Some theories may help to explain this ‘paradox’ effect, that is, why older adults experience less depressive symptoms even though they become frailer with advancing age. Cartensen,44 for example, argued in the Socioemotional Selectivity Theory (SST) that the perception of time plays a fundamental role in the selection and pursuit of social goals. Younger people view the future as being largely open and are more likely to pursue knowledge-related goals, while older people view the future as being more bounded and thus emotional goals assume primacy in this group. With advancing age, older people will become more and more motivated to regulate their emotional experiences, i.e., to maximize positive affect and to minimize negative affect, as they realize that time is increasingly limited. Therefore, older adults with advancing age are more motivated to minimize the negative affect caused by frailty for their perception of limited time.
Table 1 Participants characteristics of the whole sample and by depressive status. variables Age in years Gender Years of schooling Living alone* Monthly income (CNY) a,** Suffering from chronic disease Pain*** Cognitive impairment**** ADL score IADL score Self-rated health Social support score Frailty score
male female yes no < 3200 3200 yes no yes no yes no
Total (n = 1789)
No depression (n = 1581)
Depression (n = 208)
69.16 § 6.64 592 (33.1%) 1197 (66.9%) 8.72 § 4.24 216 (12.1%) 1569 (87.7%) 1254 (70.1%) 496 (27.7%) 1286 (71.9%) 503 (28.1%) 697 (39.0%) 1085 (60.6%) 103 (5.8%) 1684 (94.1%) 11.82 § 0.53 15.39 § 1.59 2.64 § 0.93 37.99 § 7.05 0.65 § 0.88
69.19 § 6.67 537 (34.0%) 1044 (66.0%) 8.81 § 4.21 174 (11.0%) 1404 (89.0%) 1089 (70.6%) 453 (29.4%) 1110 (70.2%) 471 (29.8%) 571 (36.3%) 1003 (63.7%) 91 (5.8%) 1489 (94.2%) 11.85 § 0.49 15.49 § 1.43 2.73 § 0.91 38.60 § 6.79 0.55 § 0.78
68.86 § 6.37 55 (26.4%) 153 (73.6%) 8.03 § 4.41 42 (20.3%) 165 (79.7%) 165 (79.3%) 43 (20.7%) 176 (84.6%) 32 (15.4%) 126 (60.6%) 82 (39.4%) 12 (5.8%) 195 (94.2) 11.57 § 0.73 14.63 § 2.40 1.99 § 0.81 33.39 § 7.37 1.41 § 1.19
* 4 missing values. ** 39 missing values. *** 7 missing values. **** 2 missing values. a CNY, China Yuan. The median household per capita disposable income of Jinan City was CNY3200 ($US 498.44) per month in 2014.
t / x2
P
0.68 4.70
0.49 0.03
2.48 14.76
0.01 < 0.001
6.84
0.009
18.88
< 0.001
45.55
< 0.001
0 5.41 5.04 12.17 9.64 14.00
0.983 < 0.001 < 0.001 < 0.001 < 0.001 < 0.001
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Fig. 1. Johnson Neyman plot of the conditional effect of physical frailty on depressive symptoms across age. The abscissa axis and the vertical axis represent age and the effect of physical frailty on depressive symptoms, respectively. The solid line that slopes downward to the right shows that the effect of physical frailty on depressive symptoms gradually declines with advancing age.
The Model of Strength and Vulnerability Integration (SAVI) recognizes not only time left as posited by the SST, but also time lived as an important mechanism whereby people gain experience and practice when dealing with daily stressors.45,46 The Selection, Optimization, and Compensation with Emotion Regulation (SOC-ER) framework suggests that older adults select and optimize specific emotional regulation strategies to compensate for changes in available resources, and subsequently show enhanced ability in emotional regulation.47 The ‘old-old’ have more effective coping mechanisms due to greater life experience, maturity and self-esteem than the ‘young old’.27 Older adults have been found to have as many emotionally close social partners as, but fewer peripheral social partners than younger adults,48 thus constructing smaller but closer social networks associated with enhanced life satisfaction.49 In addition, compared with the young-old, old-old adults recall and recognize a higher proportion of positive relative to negative information,50 which may contribute to mood repairing. Older adults also tend to increasingly rely on cognitive reappraisal to cope with limited physical resources with advancing age,51,52 and greater use of positive reappraisal strategies has been found to predict better functional status specifically among old-old adults.52,53 Meanwhile, the old-old tend to prefer passive strategies, such as accepting the problem or suppressing their feelings,54 which have been found to be more useful when stressors are beyond control.55 Together, the enhanced ability in emotional regulation may contribute to buffer the detrimental effect of frailty on emotional well-being as people age, and thus the relationship between frailty and depressive symptoms becomes weaker with advancing age. Another explanation for this ‘paradox’ effect is the Aging Brain Model (ABM), suggesting that there are age-related changes in emotion-generative brain structures, such as the amygdala.56 According to the ABM, the amygdala activation in response to negative stimuli decreases with age, while amygdala activation to positive stimuli persists across age, which diminishes emotional arousal in response to negative stimuli, correspondingly reduces the memorial advantage of high arousal negative events and ultimately reduces negative affect.56 Therefore, being frail, though a negative stimuli, is often considered as rather normal,28,57 inducing lower emotional arousal and depressive symptoms among the old-old . Given that frailty is more related to depressive symptoms in the young-old, effective interventions should be established for this population to prevent, delay, or even reverse frailty to reduce its negative effect on emotional well-being. Previous studies have indicated the
efficacy of exercise-based and (or) nutrition supplementation interventions on physical frailty.58 60 Similar interventions are also needed for older adults with advancing age, although the negative impact of frailty among the old-old is weaker than among the youngold. Further, thoughts and behaviors that promote the ‘paradox’ effect—such as interacting more often with emotionally close social partners or deploying more attention or memory on positive information—can be taught to the young-old. For example, older adults that have 3 5 network members, a medium level of contact and a high level of emotional closeness are less likely to be depressed than their counterparts.61 Additionally, older adults showed great decreases in negative affect when asked to shift their attention away from an upsetting scene to their positive memory.62 Besides the above strategies that target one specific process of emotion regulation, the Problem Adaptation Therapy (PATH),41 which aims to improve all 5 processes of emotion regulation: situation selection, situation modification, attentional deployment, cognitive change and response modulation, might be more effective in promoting the ‘paradox’ effect among the young-old. The present study had some limitations. First, we could not make any causal inferences because the study utilized a cross-sectional design. Second, the study relied on self-report measures to assess some components of physical phenotype (such as loss of weight), which might have led to recall bias. Third, the participants were enrolled in one city of China. Generalizability of our findings to other areas of China and other cultural groups might not be warranted. Conclusions The current study is the first to examine age differences in the relationship between frailty and depression among communitydwelling older adults. The relationship between frailty and depression becomes weaker as people age. This highlights that effective interventions on emotion regulation aiming to promote ‘paradox’ effects should particularly target the young-old to reduce the detrimental effect of frailty on emotional well-being. References 1. Mitchell AJ, Hari S. Prognosis of depression in old age compared to middle age: a systematic review of comparative studies. Am J Psychiatry. 2005;162:1588–1601. 2. Mueller TI, Kohn R, Leventhal N, et al. The course of depression in elderly patients. Am J Geriat Psychiat. 2004;12:22–29. 3. Stek ML, Exel E, Van, Tilburg W, Van, Westendorp RGJ, Beekman ATF. The prognosis of depression in old age: outcome six to eight years after clinical treatment. Aging Ment Health. 2002;6:282–285. 4. Hare DL, Toukhsati SR, Peter J, Tiny J. Depression and cardiovascular disease: a clinical review. Eur Heart J. 2014;35:1365–1372. 5. Rodda J, Walker Z, Carter J. Depression in older adults. BMJ. 2011;343:683–687. 6. Clegg A, Young J, Iliffe S, Rikkert MO, Rockwood K. Frailty in elderly people. Lancet. 2013;381:752–762. 7. Woods NF, LaCroix AZ, Gray SL, et al. Frailty: emergence and consequences in women aged 65 and older in the women's health initiative observational study. J Am Geriat Soc. 2010;53:1321–1330. 8. Collard RM, Boter H, Schoevers RA, Oude Voshaar RC. Prevalence of frailty in community-dwelling older persons: a systematic review. J Am Geriatr Soc. 2012;60:1487–1492. 9. Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001;56:M146–M156. 10. Gingrich A, Volkert D, Kiesswetter E, et al. Prevalence and overlap of sarcopenia, frailty, cachexia and malnutrition in older medical inpatients. BMC Geriatr. 2019;19:120. 11. Kojima G. Prevalence of frailty in nursing homes: a systematic review and metaanalysis. J Am Med Dir Assoc. 2015;16:940–945. nchez CP, Garrido JF, Martínez RN, Ros VR, Cauli O. The relationship 12. Buigues C, Sa between depression and frailty syndrome: a systematic review. Aging Ment Health. 2015;19:762–772. 13. Collard RM, Comijs HC, Naarding P, et al. Frailty as a predictor of the incidence and course of depressed mood. J Am Med Dir Assoc. 2015;16:509–514. 14. Feng L. Frailty predicts new and persistent depressive symptoms among community-dwelling older adults: findings from Singapore longitudinal aging study. J Am Med Dir Assoc. 2014;15:76.e7–76.e12.
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