Resilience among older cardiovascular disease patients with probable sarcopenia

Archives of Gerontology and Geriatrics 86 (2020) 103939

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Resilience among older cardiovascular disease patients with probable sarcopenia

T

Szu-Ying Leea, Heng-Hsin Tungb,c, , Li-Ning Pengd, Liang-Kung Chend, Ching-I Hsue, Yen-Ling Huange ⁎

a

Department of Nursing, Mackay Medical College, No.46, Sec. 3, Zhongzheng Rd., Sanzhi Dist., New Taipei City, 252, Taiwan, ROC School of Nursing, National Yang-Ming University, No.155, Sec.2, Linong Street, Taipei, 112, Taiwan, ROC c Tungs’ Taichung MetroHarbor Hospital, No.155, Sec.2, Linong Street, Taipei, 112, Taiwan, ROC d Center for Geriatrics and Gerontology, Taipei Veterans General Hospital, No. 201, Sec. 2, Shi-Pai Road, Taipei City, 11217, Taiwan, ROC e Nursing Department, Heart Center of Chen-Hsin Hospital, 45 Cheng-Hsin St, PeiTou, Taipei, 112, Taiwan, ROC b

ARTICLE INFO

ABSTRACT

Keywords: Resilience Sarcopenia Geriatric population Cardiovascular disease

Aim and objectives: The purpose of this study was to investigate the factors associated with resilience among probable sarcopenia older adults with cardiovascular disease. Introduction: Resilience has been reported to be positively correlated with the mental health and physical functioning of older adults. Previous research has found that the development of resilience constitutes a form of compensation for loss of physical health. It is important for older adults, especially those with other underlying conditions, such as cardiovascular disease and sarcopenia, to have the ability to overcome adversity during the aging process. Thus, resilience becomes a critical characteristic in achieving a better life. Methods: A cross-sectional study design was used. A demographic questionnaire and the Chinese version of the Resilience Scale (CRS) were used to collect data. Multiple logistic regression was used to evaluate the predictors of low resilience. Results: A total of 267 participants were recruited, including 126 females and 141 males. Of the participants, 56% of their scores indicated low resilience. Income, education level, exercise time, primary caregiver, and having hypertension were the predictors of resilience. Conclusion: The population with sarcopenia is increasing worldwide. Understanding resilience levels among older adults with probable sarcopenia is essential for promoting their mental health. Clinicians can use the results of this study to identify populations at high risk for low resilience and design specific interventions to promote better health outcomes.

1. Introduction Resilience promotes adaptation, resistance, or the recovery of mental and physical health after a challenge. It is also a process of reacting to, learning about, and overcoming adversity (Gillespie, Chaboyer, & Wallis, 2017; Wagnild & Young, 1993; Kralik, van Loon, & Visentin, 2006). Resilience is one way in which an individual may respond to stress, allowing the individual to adapt to stressors, and health-related problems or reduce their negative influence (Basim & Cetin, 2011; Ghanei Gheshlagh et al., 2016). With sufficient resilience, individuals have the ability to cope with the negative effects of stress

and face challenging life changes (Kralik et al., 2006). Resilience may serve as a useful predictor of mental health status in older adults, as older adults commonly face adversity (Liu & Chiou, 2012; Nygren et al., 2005; Rutter, 2012; Yang, Graeme, & Liu, 2013). Resilience involves five main characteristics: self-reliance, perseverance, equanimity, meaningfulness, and existential aloneness (Wagnild, 2009). Self-reliance means trusting in one’s personal abilities to support and guide one’s decisions and actions, as based on past successful experiences. Perseverance means that, despite facing adversity or frustration, an individual is willing to work hard to persist, overcome difficulties, and rebuild their life. Equanimity means that an

Abbreviations: EWGSOP, European Working Group on Sarcopenia in Older People; AWGS, Asian Working Group for Sarcopenia; CRS, Chinese version of the Resilience Scale; CAD, coronary artery disease; BMI, body mass index; CHF, congestive heart failure ⁎ Corresponding author at: School of Nursing, National Yang-Ming University, No.155, Sec.2, Linong Street, Taipei, 112, Taiwan, ROC. E-mail addresses: [email protected] (S.-Y. Lee), [email protected] (H.-H. Tung), [email protected] (L.-N. Peng), [email protected] (L.-K. Chen), [email protected] (C.-I. Hsu), [email protected] (Y.-L. Huang). https://doi.org/10.1016/j.archger.2019.103939 Received 14 May 2019; Received in revised form 18 August 2019; Accepted 18 August 2019 Available online 19 August 2019 0167-4943/ © 2019 Elsevier B.V. All rights reserved.

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individual is able to strike a balance in life and maintain a sense of humor in the face of adversity, making it easier to manage. Meaningfulness refers to the meaning that one sees in one’s life, including comprehending the value of participation and achieving life goals. Existential aloneness refers to the sense that each individual is unique, such that, although experiences can be shared, one still has to face life’s challenges alone to some degree (Wagnild & Young, 1993; Wagnild, 2009). Aging typically results in a gradual decline in physical function, with the loss of skeletal muscle as one of the phenomena of aging, which can lead to sarcopenia. Skeletal muscle degeneration starts at the age of 30, with thigh muscle loss that occurs at rates of 10–15% and 25–40% per decade at ages over 40 and 70 years, respectively (Kim & Choi, 2013). Sarcopenia is currently classified based on three diagnostic criteria in clinical practice by the European Working Group on Sarcopenia in Older People (EWGSOP): low muscle mass, low muscle strength, and low physical performance (Cederholm & Morley, 2015; Cooper et al., 2013). Although the EWGSOP operational definition has been used widely in screening processes for sarcopenia, due to differences in body size among Asians and Europeans, it is recommended that the screening cut-off points should be different for these populations. Therefore, the Asian Working Group for Sarcopenia’s (AWGS) screening method of measuring the calf circumference might be better suited for Taiwanese people (Chen et al., 2014). This method has the advantages of being a simple, effective, and inexpensive method of evaluating skeletal muscle mass (Kawakami et al., 2015; Martinez et al., 2015). In addition to sarcopenia’s association with aging, research has shown that sarcopenia is associated with gender, lifestyle, nutrition, exercise, and chronic disease (Cederholm & Morley, 2015; Cruz-Jentoft et al., 2010; Kwan, 2013). Older adults with sarcopenia are more likely to have increased incidences of falls, injuries, or hospitalizations due to declines in muscle mass and strength (Cruz-Jentoft et al., 2010). As older patients encounter new situations, their usual resilience strategies may be ineffective, compelling them to search for new strategies to adopt when they are diagnosed with chronic diseases, such as sarcopenia (de Ridder, Geenen, Kuijer, & van Middendorp, 2008). Notably, sarcopenia contributes to cardiovascular disease, which has been reported in previous studies (Chin et al., 2013; de Lemos, Moraes, & Pellanda, 2016; Han, Yu, & Ma, 2017). Studies of the resilience of older adults have found that 53.2% of patients with coronary artery disease (CAD) have lower resilience scores than the overall average of other older adults and that levels of resilience are significantly correlated with age, gender, education level, occupational status, income, family support, and past history of hypertension (Azam, Arsalan, Ali, Leila, & Fatemeh, 2015; Liu, Chang, Wu, & Tsai, 2015; Nouri-Saeed, Salari, Nouri-Saeed, Rouhi-Balasi & Moaddab, 2015; Stewart & Yuen, 2011). A study of the resilience of 546 older adults showed that male gender, living with others, having better hand-grip strength, and having greater independence in life were associated with higher resilience scores (Hardy, Concato, & Gill, 2004). Other research, however, has found that women have better resilience than men (Li, 2008; Netuveli, Wiggins, Montgomery, Hildon, & Blane, 2008). In addition, one study found a strong relationship between resilience and chronic disease, with the average resilience scores being lower in patients who have a chronic disease or cardiovascular disease (Ghanei Gheshlagh et al., 2016). Pervious evidence has indicated that higher levels of resilience help patients to overcome the negative effects of stressful life events (Leppin et al., 2014). Most of the studies discussed above were conducted in Western countries and focused mainly on general populations rather than specifically on older adults with both cardiovascular disease and sarcopenia. There are few studies that focus on the relationships between sarcopenia, resilience, and cardiovascular disease in the geriatric population. Further, the relationships among demographics, resilience, and cardiovascular disease have not been extensively studied. Thus,

additional work is needed to investigate the influence of demographics and resilience status in patients with sarcopenia. To address this gap, this study was conducted to investigate the factors associated with resilience among older adult cardiovascular disease patients with sarcopenia. 2. Methods 2.1. Research design and study sample In this study, we used a cross-sectional research design. These study data were part of the project, “Resilience, nutrition, and physical activity in sarcopenia older adults with cardiovascular disease-qualitative and quantitative longitudinal research,” funded by the Ministry of Science and Technology (MOST106-2314-B-010-059-MY3). The data was collected at two hospitals in Taipei City, Taiwan and received Institutional Review Board approval from both of the hospitals. Participants were recruited from out-patient clinic. The inclusion criteria were: (1) diagnosed with probable sarcopenia by revised EWGSOP criteria with AWGS cutoff (handgrip strength under 26 kg for men and 18 kg for women, gait speed with a cut-off point of ≤ 0.8 m/s, and calf circumference < 34 cm for men and < 33 cm for women); (2) diagnosed with cardiovascular disease; (3) able to read Chinese; and (4) aged 65 years and over. Patients with a psychiatric diagnosis who had a neoplasm were excluded. Eligible participants were informed of the nature and goals of this study and completed the study questionnaire. The research received ethical approval from the institutional review board of the hospital. 2.2. Measurements A demographic questionnaire and the Chinese version of the Resilience Scale (CRS) were used to assess the participants in the study (Yang, 2008). There are 25 items in this scale, with each answered on a 7-point (1–7) rating scale. The total score thus ranges from a minimum of 25 to a maximum of 175. The CRS has five domains: perseverance, equanimity, meaningfulness, self-reliance, and existential aloneness. The total resilience score is classified into one of three categories: scores over 145 indicate the highest levels of resilience, scores from 120 to 145 indicate moderately high to high levels of resilience, and scores below 120 indicate low levels of resilience (Lei et al., 2012; Yang et al., 2013). The internal consistency and content validity of the CRS are considered good (Lei et al., 2012; Yang et al., 2013). A previous study indicated that, for older adults who had heart failure, the Cronbach’s alpha of the CRS was 0.96 (Liu et al., 2015). It is thus reasonable to apply the CRS in this study to explore the level of resilience among the participants. The Cronbach’s alpha value for the CRS was 0.94 in the present sample. 2.3. Data analysis SPSS for Windows, Version 20.0, was used for statistical analysis. The two-tailed significance level was p < .05. Continuous variables are presented as mean (M) ± standard deviation (SD), and categorical variables are presented as case number (n) and percentage (%). Independent t-tests and chi-squared tests were performed to determine whether there were differences in demographic and categorical data, respectively, between the low-resilience patients and the other patients. Multiple logistic regression was used to evaluate the odds ratio (OR) of possible predictors of low resilience. 3. Results 3.1. Demographics of probable sarcopenia in older adults The sample consisted of 267 participants. The CRS scores of the 2

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S.-Y. Lee, et al.

participants were classified into two categories: patients with resilience scores of 120 or lower were identified as the low-resilience group, while those with scores above 120 were identified as the moderately high- to high-resilience group, which we named the normal group. The lowresilience group had 150 participants, while the other group had 117. The mean age had similar values and standard deviations in the two groups (83.3 ± 7.02 years vs. 82.93 ± 8.30 years). The low-resilience group weighed less, on average, than did the normal group (54.1 ± 10.12 kg vs. 58.4 ± 9.33 kg). In the low-resilience group, the largest percentages of the participants were female (53.3%), married (96.7%), and over 85 years old (44.7%). In addition, 55.3% of these participants had the ability to read and write, and 77.3% were low income. In the moderately high- to high-resilience group, the largest percentage of the participants were male (60.7%), married (95.7%), and over 85 years old (44.4%). In addition, 37.6% of these participants had the ability to read and write, and 66.7% were low income. In terms of the type of cardiovascular disease, the most common cardiovascular disease was hypertension (40%) in the low-resilience group, but it was CAD (41%) in the normal group. Our evaluation of the associations between resilience and sociodemographic features indicated significant relationships with body weight, body mass index (BMI), gender, education status, primary caregiver, exercise time, and cardiovascular disease status (Table 1).

Table 1 Univariate analysis of demographic variables (N = 267).

3.2. Resilience of older adults with probable sarcopenia Overall, differences in body weight, gender, education level, primary caregiver, exercise time, and resilience group were associated with significant differences in CRS scores. The overall mean CRS score was 118.29 ± 25.67. In the low-resilience group, it was 100.25 ± 16.8 as compared to 141.41 ± 13.7 in the normal group. With regard to the five subscales of the CRS, the order from highest to lowest scores was existential aloneness (z-score = 4.89), meaningfulness (z-score = 4.72), self-reliance (z-score = 4.66), equanimity (z-score = 4.59), and perseverance (z-score = 4.28). For the five subscales of the CRS, body weight was strongly correlated with CRS scores (r = .21, p < .01), except those for meaningfulness (r = .08), with heavier body weights associated with better resilience levels. Gender also was associated with significant differences in the CRS scores (p = .03), with men having better resilience than women overall, and in the subscales of self-reliance and perseverance, respectively (p = .01, p = .03). In terms of education, those with education levels of college or higher had better resilience than did those with other education levels, including significant differences in self-reliance, perseverance, and equanimity, respectively (p < .001, p = .001, p < .001). Better incomes were correlated with meaningfulness and existential aloneness (p = .01, p = .02). The variables of primary care, exercise time, and resilience group also were associated with significant differences in the overall CRS scores (all variables p < .001) and with scores for the five subscales, with the exception of exercise time and the subscale of existential aloneness (p = .15). Overall, patients who engaged in self-care and had more exercise time had better resilience (Table 2). The multiple logistic regression analysis demonstrated that patients with an educational level of college or higher had a low risk of having low resilience (OR: 0.366, CI: .15–.88, p = .026). An educational level of senior high school was also associated with a low risk of having low resilience (OR: 0.463, CI: .23–.93, p = .03). In addition, an income above 30,000 Taiwanese dollars was associated with a low risk of having low resilience (OR: 0.47, CI: .26–.85, p = .012). Patients taken care of by others had a high risk of having low resilience (OR: 3.01, CI: 1.68–5.39, p < .001). Hypertension also was associated with a high risk of having low resilience (OR: 3.07, CI: 1.50–6.27, p = .002). Having congestive heart failure (CHF) or a valve disease, however, did not confer any risk of low resilience (Table 3).

Low resilience (n = 150)

Normal (n = 117)

Variable

M/%

SD

M/%

SD

t/X2

p

Age Body weight BMI Gender Male Female Age 65–75 years 76–85 years Over 85 years Marital status Single Married Education Literacy Junior high school Senior high school College and higher Income ≤30,000 > 30,000 Primary caregiver Self-care Other Living situation Live with family Live alone Live in nursing home Religion None Buddhism Christianity Exercise Yes No Exercise time ≤30 min > 30 min Cardiovascular disease Hypertension Valve disease CAD Heart failure

83.3 54.1 21.8

7.0 10.1 3.4

82.9 58.4 23.2

8.3 9.3 3.3

70 80

46.7 53.3

71 46

60.7 39.3

37.88 40.95 103.40 5.81

.70 .00** .02* .02*

22 61 67

14.7 40.7 44.7

26 39 52

22.2 33.3 44.4

3.02

.22

5 145

3.3 96.7

5 112

4.3 95.7

0.00

.98

83 14 37 16

55.3 9.3 24.7 10.7

44 16 31 25

37.6 10.3 30.8 21.4

11.90

.01**

116 34

77.3 22.7

78 39

66.7 33.3

3.65

.05

47 103

31.3 68.7

66 51

56.4 43.6

16.80

< .001***

120 14 16

80.0 9.3 4.7

101 8 8

86.3 6.8 6.8

2.07

.35

39 88 23

26.0 58.7 15.3

34 70 13

29.1 59.8 11.1

0.21

.77

100 50

66.7 33.3

85 32

72.6 27.4

2.74

.25

113 37

75.3 24.7

66 51

56.4 43.6

10.65

< .001***

60 38 33 19

40 25.3 22 12.7

26 38 41 12

22.2 32.5 35 10.3

11.97

< .001***

4. Discussion The present study is the first to investigate the factors associated with resilience among probable sarcopenia older adults with cardiovascular disease. In comparison with non-sarcopenia older adults, the overall resilience scores of probable sarcopenia older adults with cardiovascular diseases are lower than those of elderly residents in longterm care facilities and lower than those of community-dwelling older adults (The average score of CRS was 124.51) (Liu & Chiou, 2012; Yang, 2008). Probable sarcopenia older adults with cardiovascular diseases have lower resilience and need to pay more attention to their mental health, particularly perseverance. Integrating psychological care resources and providing coping strategies for this population could help to strengthen their resilience, improve their stress-coping capability, and reduce the adverse effects of stressful events. A high proportion of the participants in this study had low resilience, which showed a strong relationship with body weight, gender, education level, income, primary caregiver, cardiovascular disease, and exercise time. Men had better resilience than did women, a finding that was similar to that of Hardy et al. (2004) in their study of communitydwelling older adults. Other studies, however, have indicated that 3

M ± SD

Variable

4

± ± ± ±

23.99 23.78 22.35 27.07

± ± ± ±

22.42 25.82 22.53 17.81

< .001***

< .001***

.53

< .001***

.14

< .01***

.30

.18

r = .21** .03*

p-value

± ± ± ±

7.47 6.83 6.73 8.07

± ± ± ±

7.07 7.51 7.38 4.155

23.64 ± 5.91 33.33 ± 5.50

26.27 27.20 29.08 34.47

29.09 ± 6.32 27.30 ± 7.99 28.22 ± 6.84

30.35 ± 6.84 26.12 ± 7.37

28.11 ± 6.51 27.38 ± 9.50

26.45 27.30 29.52 29.97

27.83 ± 7.49 30.10 ± 5.66

28.16 ± 8.71 26.59 ± 7.57 28.93 ± 6.62

29.01 ± 6.94 26.69 ± 7.79

M ± SD

4.65

27.92 ± 7.44

Self-reliance

< .001***

< .001***

.22

< .001***

.43

< .01***

.24

.06

r = .23** .01**

p-value

± ± ± ±

7.93 6.66 7.13 8.02

± ± ± ±

6.71 8.30 7.05 7.73

33.06 ± 6.10 46.15 ± 5.64

32.51 33.28 35.67 34.24

34.94 ± 7.31 34.19 ± 7.59 33.05 ± 7.59

36.53 ± 7.87 32.57 ± 7.20

33.72 ± 6.68 35.64 ± 9.91

32.67 35.69 35.30 36.31

34.09 ± 7.75 38.20 ± 6.28

35.79 ± 8.90 33.30 ± 7.93 34.42 ± 6.96

35.19 ± 6.73 33.19 ± 8.61

M ± SD

4.28

34.25 ± 7.73

Perseverance

Note. a. Pearson’s correlation coefficient; b: independent t-test; c: one-way analysis of variance (ANOVA). Note. CRS means Chinese version of the Resilience Scale. *** p < 0.001.

100.25 ± 16.80 141.41 ± 13.73

107.63 110.64 118.83 136.52

116.19 ± 23.70 112.40 ± 25.25 114.02 ± 23.95

121.72 ± 24.46 107.74 ± 23.09

112.37 ± 21.09 117.06 ± 32.13

107.65 116.00 118.46 122.21

113.35 ± 24.76 121.60 ± 20.35

118.72 ± 28.06 110.79 ± 23.93 114.02 ± 23.57

116.77 ± 22.55 110.17 ± 26.43

4.5

Z-score

Body weighta Genderb Male Female Agec 65–75 years 76–85 years > 85 years Marital statusb Married Single Educationc Literacy Junior high Senior high College+ Incomeb ≤30,000 > 30,000 Primary caregiverb Self Other Religionc None Buddhism Christianity Exercise timec 0 mins ≤30 mins > 30–60 mins > 60 mins Resilience groupb Low Normal

113.65 ± 24.63

Mean ± SD

Resilience Scale

Table 2 Analysis of demographic variables and CRS scores.

< .001***

< .001***

.48

< .001***

.07

.01**

.07

.17

r = .22** .03*

p-value

± ± ± ±

6.59 7.52 5.86 7.04

± ± ± ±

6.67 7.12 5.982 6.83 23.31 ± 5.22 33.03 ± 4.65

26.44 26.73 28.98 31.17

28.01 ± 6.71 27.03 ± 7.07 28.80 ± 5.82

29.05 ± 7.07 26.42 ± 6.44

27.20 ± 6.14 28.43 ± 8.37

25.48 28.92 29.13 30.19

27.52 ± 6.85 27.80 ± 6.56

28.54 ± 7.49 27.19 ± 6.47 27.42 ± 6.86

28.25 ± 6.20 26.73 ± 7.41

M ± SD

4.59

27.54 ± 6.83

Equanimity

< .001***

< .001***

.29

< .001***

.18

< .01***

.90

.51

r = .15** .07

p-value

± ± ± ±

4.22 4.20 3.36 4.55

± ± ± ±

3.98 4.06 3.71 3.05 11.59 ± 3.01 17.49 ± 2.73

13.05 13.62 15.12 18.29

14.00 ± 4.21 14.20 ± 4.06 14.33 ± 4.13

15.26 ± 4.33 13.36 ± 3.73

13.77 ± 3.68 15.20 ± 4.92

13.48 14.96 14.49 15.21

14.14 ± 4.12 14.80 ± 3.64

15.75 ± 4.34 14.21 ± 3.99 13.49 ± 3.93

14.34 ± 3.90 13.97 ± 4.31

M ± SD

4.72

14.16 ± 4.10

Meaningfulness

< .001***

< .001***

.09

< .001***

.01*

.05

.59

.00**

r = .08 .47

p-value

8.35 ± 2.25 11.56 ± 1.89

9.34 ± 2.52 9.79 ± 2.60 9.95 ± 2.73 10.88 ± 2.61

10.13 ± 2.52 9.66 ± 2.69 9.61 ± 2.57

10.52 ± 2.47 9.24 ± 2.61

9.55 ± 2.28 10.39 ± 3.31

9.55 ± 2.66 9.11 ± 2.67 10.01 ± 2.35 10.51 ± 2.83

9.75 ± 2.63 10.70 ± 2.49

10.47 ± 2.96 9.50 ± 2.73 9.74 ± 2.35

　 9.97 ± 2.32 9.57 ± 2.93

M ± SD

4.89

9.79 ± 2.63

< .001***

.15

.40

< .001***

.02*

.09

.26

.10

r = .18** .23

p-value

Existential aloneness

S.-Y. Lee, et al.

Archives of Gerontology and Geriatrics 86 (2020) 103939

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well as for contributing to well-being. Having the capability for selfcare indicates independence rather than reliance on others. Past studies have shown that families are an essential source of primary support for most Chinese older adults and a recognized determinant of health; having a primary caregiver can also contribute to the resilience of the elderly (Hai et al., 2017; Kamen, Cosgrove, McKellar, Cronkite, & Moos, 2011) and help them to retain some of their independence. Although older adults expect that they will need help when physical function declines, in terms of mental health, they expect to be able to rely on their own abilities to overcome adversities. In this regard, resilience is related to self-esteem or having a strong sense of self-worth (Kralik et al., 2006). Importantly, family accompaniment, encouragement, and emotional support are the key factors in the mental health of older adults. Family support also affects the services received by the elderly with chronic diseases (Kamen et al., 2011). The present study also found that time spent with exercise is strongly associated with resilience level for older adults with probable sarcopenia. More exercise time is likely to result in better resilience status. This is in keeping with the findings of other studies that physical activity is one of the important factors in decreasing the incidence of sarcopenia and in further promoting mental health status (Liu & Chiou, 2012; Tanimoto et al., 2013; Wang & Bai, 2012). Physical activity is an effective protective strategy for sarcopenia, and increased exercise frequencies might be helpful for this population (Chan et al., 2017; Gill et al., 2017). Targeted physical activity interventions may be developed, and the physical activity of patients can be reported in their medical records, with the benefit of potentially preventing sarcopenia and increasing resilience levels. A major limitation of the study was that all of the participants were recruited in Taipei districts only. Therefore, the findings might not be representative of various districts. The present study also used a crosssectional and observational design; therefore, no assumptions of causation can be made, and long-term observations of mental health status were not possible. The use of multiple time points to collect changes of resilience in the probable sarcopenia population for the run and design a specific intervention to promote resilience level should be considered in future research.

Table 3 Results of multiple logistic regression analysis. Variable Education (reference: Literacy) College High school Income (reference: NTD ≤ 30 K) Primary caregiver (reference: Self-care) Cardiovascular diseases (reference H/T CHF Valve

β

SE

OR

95% CI

p-value

−1.00 −.77 −.75 1.10

0.45 0.35 0.30 0.39

0.37 0.46 0.47 3.01

0.15–0.88 0.23–0.93 0.26–0.85 1.68–5.39

.026* .030* .012* < .001***

group: CAD) 1.12 0.36 0.64 0.47 0.19 0.37

3.07 1.89 1.22

1.50–6.27 0.75–4.76 0.59–2.52

.002** .170 .590

women have better resilience than men (Li, 2008; Netuveli et al., 2008), contrary to the findings of the present study. In addition, in this study, men had better self-reliance and perseverance. Cultural diversity might explain these findings to some extent, as men typically have to take responsibility for the economic well-being of a family under the traditional social perspective in Asian countries. With regard to age, this sample showed that younger older adults (65–75 years) had better meaningfulness scores, indicating that they viewed life as valuable and meaningful, even though age was not associated with the total resilience score. This finding was inconsistent with that of Shen and Zeng’s (2010) study, which indicated that younger older adults had greater resilience. Aging is often associated with the occurrence of chronic diseases, and, in this study, patients with hypertension and probable sarcopenia showed lower resilience. Previous studies have reported similar findings, such as the finding that CAD with a history of hypertension and an acute myocardial infarction diagnosis showed lower resilience or the observation of significantly lower resilience in congestive heart failure patients compared with that of the general population (de Lemos et al., 2016. Liu et al., 2015; NouriSaeed et al., 2015). Therefore, patients who have probable sarcopenia with cardiovascular disease need to be more concerned about their resilience. In this study, patients with higher education levels tended to have better resilience, consistent with previous studies (Azam et al., 2015; Liu & Chiou, 2012; Liu et al., 2015). Nevertheless, meaningfulness and existential aloneness were not associated with education level in our study. People need to face various life situations alone, even if they have some assistance or higher levels of education. Resilience, however, could allow for adaptions to be made through a learning process (Kralik et al., 2006). Although most of the sample in the present study did not have high levels of education, they could advance their resilience capacity through learning and training to be adaptable. In this study, lower income was associated with low resilience, consistent with Wagnild (2003), who found that lower income was correlated with lower resilience and a higher prevalence of health risk factors. Further, employment status is viewed as a significant predictor of resilience, and sufficient socioeconomic resources have been reported to be an important factor in regard to resilience (Azam et al., 2015; Hoare, 2015). All of the participants in the present study were 65 year of age and older, and most were retired. For most, then, their incomes depended on either a pension or family supplement. Thus, in this study, low income might have indicated lower resilience (Azam et al., 2015). Better economic conditions might help older adults to achieve their goals in life and to feel that life is valuable. One new finding of the present study was that older adults who have the ability to take care of themselves have better resilience than those taken care of by others. Christy (2017) noted the value of fostering resilience in the face of stress and adversity and the importance of selfcare for healthy lifestyle changes and stress management behaviors as

5. Conclusions Resilience is a useful predictive factor to evaluate the mental health status of the elderly, and this study found that over half of its older adult participants had low resilience. The findings of this study might be useful in clinical contexts, as it is important for clinicians to recognize and assess resilience in their patients and to help their patients to improve their resilience to better cope with different types of adversity to recover or to overcome difficult times successfully. Author contributions H- H T and S-Y L were responsible for this study’s design. The participants were obtained by S-Y L, L-N P, L-K C, C-I H, and Y-L H from two hospitals. H- HT supervised the study. was responsible for the drafting and revising of the manuscript. H- H T, S-Y L, L-N P, and L-K C approved the final manuscript. Funding source This project was supported by the Ministry of Science and Technology, Taiwan (MOST106-2314-B-010-059-MY3). Declaration of Competing Interest All of the authors declare that there were no conflicts of interest.

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Acknowledgments

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