RESILIENCE AND MORTALITY IN OLDER ADULTS: STRUCTURAL EQUATION ANALYSISABSTRACT
Objective: to compare sociodemographic and health variables between older adults who died and survivors, identify resilience as a predictor of mortality among older adults in the community and verify the direct and indirect associations between resilience and mortality.
Method: a quantitative, longitudinal study, carried out with 201 older adults from the community, in two moments: 2018 and 2022. Instruments validated in Brazil were used. Data were subjected to the Wilcoxon test and structural equation modeling analysis (p<0.05).
Results: higher proportion of older male adults (p=0.023), with five or more diseases (p=0.043), depressive symptoms (p<0.001), negative self-perceived health (p<0.001), less participation in advanced activities of daily living (p=0.004) and lower resilience score (p<0.001) died compared to survivors. The highest resilience score reduced the risk of mortality from all causes (p<0.001). The lowest resilience score was directly associated with higher mortality (p=0.025). It was found that a higher resilience score, mediated by greater participation in advanced activities of daily living (p<0.05) and positive self-perceived health (p<0.05), was associated with lower mortality.
Conclusion: older adults with a higher resilience score had a lower risk of mortality throughout follow-up. Greater participation in advanced activities of daily living and positive self-perceived health mediated the relationship between higher resilience scores and lower mortality.
DESCRIPTORES Aged; Resilience psychological; Longitudinal studies; Mortality; Geriatric nursing
RESUMEN
Objetivo: comparar variables sociodemográficas y de salud entre ancianos fallecidos y sobrevivientes, identificar la resiliencia como predictor de mortalidad entre ancianos de la comunidad y verificar las asociaciones directas e indirectas entre resiliencia y mortalidad.
Método: estudio cuantitativo, longitudinal, realizado con 201 ancianos de la comunidad, en dos momentos: 2018 y 2022. Se utilizaron instrumentos validados en Brasil. Los datos fueron sometidos a la prueba de Wilcoxon y análisis de modelado de ecuaciones estructurales (p<0,05).
Resultados: mayor proporción de hombres mayores (p=0,023), con cinco o más enfermedades (p=0,043), síntomas depresivos (p<0,001), autopercepción negativa de la salud (p<0,001), menor participación en actividades avanzadas de salud vida diaria (p=0,004) y menor puntaje de resiliencia (p<0,001) murieron en comparación con los sobrevivientes. La puntuación más alta de resiliencia redujo el riesgo de mortalidad por todas las causas (p<0,001). El puntaje de resiliencia más bajo se asoció directamente con una mayor mortalidad (p=0,025). Se encontró que una mayor puntuación de resiliencia, mediada por una mayor participación en actividades avanzadas de la vida diaria (p<0,05) y una autopercepción positiva de la salud (p<0,05), se asoció con una menor mortalidad.
Conclusión: los ancianos con mayor puntaje de resiliencia tuvieron menor riesgo de mortalidad a lo largo del seguimiento. Una mayor participación en actividades avanzadas de la vida diaria y una autopercepción positiva de la salud mediaron la relación entre mayores puntuaciones de resiliencia y menor mortalidad.
DESCRIPTORS: Anciano; Resiliencia psicológica; Estudios longitudinales; Mortalidad; Enfermería geriátrica
RESUMO
Objetivo: comparar as variáveis sociodemográficas e de saúde entre idosos que foram a óbito e os sobreviventes, identificar a resiliência como preditora de mortalidade entre idosos da comunidade e verificar as associações, diretas e indiretas, entre resiliência e mortalidade.
Método: estudo quantitativo, longitudinal, realizado com 201 idosos da comunidade, em dois momentos: 2018 e 2022. Utilizaram-se os instrumentos validados no Brasil. Os dados foram submetidos ao teste de Wilcoxon e análise de modelagem de equações estruturais (p<0,05).
Resultados: maior proporção de idosos do sexo masculino (p=0,023), com cinco ou mais doenças (p=0,043); sintomatologia depressiva (p<0,001); autopercepção de saúde negativa (p<0,001), menor participação em atividades avançadas de vida diária (p=0,004) e menor escore de resiliência (p<0,001) foram a óbito em relação aos sobreviventes. O maior escore de resiliência reduziu o risco de mortalidade por todas as causas (p<0,001). O menor escore de resiliência associou-se diretamente à maior mortalidade (p=0,025). Verificou-se que o maior escore de resiliência mediado pela maior participação em atividades avançadas da vida diária (p<0,05) e pela autopercepção de saúde positiva (p<0,05) associaram-se à menor mortalidade.
Conclusão: idosos com maior escore de resiliência apresentaram menor risco de mortalidade ao longo do seguimento. A maior participação em atividades avançadas da vida diária e autopercepção de saúde positiva mediaram a relação entre maior escore de resiliência e menor mortalidade.
DESCRITORES: Idoso; Resiliência psicológica; Estudos longitudinais; Mortalidade; Enfermagem geriátrica
INTRODUCTION
Scientific studies have expanded investigations that address resilience in aging, aiming to understand how to overcome adversities in older adults’ lives1-2.
It is noteworthy that, at this stage of life, older adults may experience adversities related to physical and cognitive decline, biological vulnerability, feelings of social uselessness, loss of independence, grief, social prejudice, reduced functional capacity and financial difficulties2-3. Furthermore, adverse events can lead to mental health problems in older adults, which can cause depression and low quality of life4. Such risk perspectives, considered together, suggest that increased resilience in aging is necessary so that adaptive behavior is maintained4.
Resilience refers to a pattern of positive adaptation and the ability to find resources to act, adapt and recover in the face of and after adverse situations5. People exposed to these experiences show considerable heterogeneity in their responses. Thus, the processes that encompass positive adaptation in the face of significant adversity have been defined as resilience6.
From this perspective, the development of the resilience process allows older adults to achieve flexibility, psychological well-being and, consequently, a better quality of life, employing positive responses to setbacks7. Promoting their well-being in the face of increasing adversity has implications for aging individuals and society8.
Despite the growing scientific literature on the subject, methods to improve resilience among older adults still need to be expanded and deepened9, and the same occurs with the study of resilience as a predictor of mortality, especially in older adults10. Thus, knowledge about these aspects and the way in which older adults react to changes and their feelings contribute to early interventions that enable health promotion9.
A study carried out with the general population in Italy found that resilient people are more likely to have healthier behaviors, expressed in higher levels of physical activity and greater adherence to a healthy diet10. This research also observed a 20% reduction in the risk of mortality, from all causes, associated with a higher resilience score10.
A review study found that a third of investigations with older adults presented a high resilience score, indicating that increasing it may be a promising strategy to improve the quality of life of this population9. Therefore, to promote the well-being of this group and increase the general understanding of aging, it is appropriate to assess psychobiological responses to adverse situations and, consequently, on health, which may reflect on mortality reduction3.
A survey found that positive self-perceived health, in the face of chronic non-communicable diseases, encourages individual changes in behavior and can thus contribute to reducing deaths and hospitalizations11. In this way, increased responsibility for self-care contributes to older adults’ ability to maintain health and mitigate the challenges associated with their limitations, and the presence of resilience may be relevant when considering how individual factors modulate this self-care11. This resilient behavior influences their adaptation to health challenges and consequently reduces mortality11.
Furthermore, gerontological literature highlights that advanced activities of daily living (AADL) can indicate good physical and mental health, and its reduction suggests the beginning of functional decline, cognitive changes and frailty. Thus, older adults who have difficulty performing AADL may be at greater risk for future losses, therefore increasing the chances of death from all causes11.
In this context, this study aimed to compare sociodemographic and health variables between older adults who died and survivors, in addition to identifying resilience as a predictor of mortality among older adults in the community and verifying direct and indirect associations between resilience and mortality.
METHOD
This is research with a quantitative and longitudinal approach, carried out in two moments: 2018 and 2022.
The study population consisted of older adults living in a rural municipality in Minas Gerais, Brazil. The sample calculation was carried out by a multistage cluster sampling. In 2018, the coefficient of determination R²=0.02 was considered in a multiple linear regression model with 10 predictors, with a level of significance or type I error of α=0.05 and type II error of β= 0.2, thus finding a, a priori, statistical power of 80%. These values were introduced into Power Analysis and Sample Size (PASS) version 13, reaching a sample size of n=806 older adults.
Older adults aged 60 or over, without cognitive decline, residing in the urban area of the municipality and who participated in the interviews in 2018 and 2022 were included. Older adults with communication problems such as deafness, not corrected by devices, as well as serious disorders of speech, were excluded. In the second moment of data collection (2022), older adults who did not answer the calls, after five attempts at different times and days, and when there was no data completeness during the interviews, were also excluded.
In 2018, 808 older adults were interviewed at home. The first stage of this research consisted of 791 older adults who had data completeness and met the eligibility criteria. To recruit the aforementioned sample (2018), a multistage cluster sampling was used. Thus, the selection of older adults considered an arbitrary draw of 50% of the city’s 404 eligible census tracts through systematic sampling. Subsequently, a single list was organized, identifying the neighborhood that older adults belong to, randomly drawing the first one to be interviewed, with the others considering standardized direction. Subsequently, the number of households to be selected was calculated, which was divided by the number of census sectors in the municipality so that a similar number was maintained within each one. The number of households/older adults was four older adults per census tract.
To begin collection, the streets were numbered and entered into Statistical Package for the Social Sciences (SPSS)® version 21.0 to carry out a random draw of the street that would be the starting point for the search for older adults/household. Data collection began at the first residence on the street selected, proceeding clockwise. All households were visited sequentially, until obtaining the number of older adults who met the inclusion criteria in that sector.
The interviewers were trained to fill out the instruments correctly, in addition to carrying out physical tests in a standardized manner and with an appropriate approach to the interviewee. Intercurrences (deaths, refusals, absences) were noted in a field spreadsheet.
Data quality control was carried out by field supervisors by checking data completion and consistency. Meetings were held between field supervisors and the researcher in charge for follow-up. Furthermore, 10% of older adults in the sample received a telephone call from one of the supervisors to ensure that the interviews were actually being carried out and with the desired quality and standardization.
As the interviews were carried out, coding and review were carried out. An electronic spreadsheet in Microsoft Excel® was created, and the data was processed on a microcomputer in double entry to check for inconsistencies. When there were inconsistent data between the two databases, they were checked in the original interview and corrected.
In the second moment (2022), due to the COVID-19 pandemic, the interviews were conducted by telephone. An attempt was made to contact all older adults who participated in data collection in 2018 from January to September 2022. Data were collected by the researcher and trained research assistants, recruited based on previous experience in data collection in health research. Initially, older adults were contacted by phone, and for those whose phone was not answered/changed, the number was searched using the address in the municipality’s telephone directory, thus aiming to avoid the greatest number of possible losses.
In the first telephone contact, the interviewers identified themselves, explained the research objectives, inviting older adults to participate in the study. The interview lasted approximately 15 minutes.
It was identified that, of the 791 older adults who made up the sample in 2018, 100 died; two did not have the cognitive ability to answer questions according to information from family members; 42 refused; and 446 were not located, either because the telephone number did not exist or belonged to someone else, or because no one answered the call after five attempts on different days and times. Thus, the final sample of this study consisted of 201 older adults.
Data collection related to mortality was obtained through information from family members via telephone and through the Brazilian National Registry of Deceased Persons (CNF - Cadastro Nacional de Falecidos). The website www.falecidosnobrasil.org.br and the service of the City Hall of Uberaba, MG, Brazil, on the website http://servico.uberaba.mg.gov.br/cemiterio/cemiterio/sepuldados.php, in the tab “Consulta Sepultados”, were consulted.
In the 2018 collection, printed instruments were used: Questionnaire on sociodemographic characteristics, prepared by the Universidade Federal do Triângulo Mineiro Public Health Research Group; Katz Index, prepared by Katz (1963) and adapted to the Brazilian reality12-13; Geriatric Depression Scale (GDS-15), proposed by Yesavage in 1986 and validated in Brazil by Almeida and Almeida (1999)14, Connor-Davidson Resilience Scale for Brazil-25 (CD-RISC-25BRASIL)15-16; Advanced Activities of Daily Living Questionnaire17; Lawton and Brody Scale18; and Brazilian Older Americans Resources and Services Multidimensional Function Assessment Questionnaire (BOMFAQ)19.
In 2022, new data were collected from CD-RISC-25BRASIL15-16, which were entered into Microsoft Excel® and data relating to mortality, obtained through information from family members in telephone contact and through CNF.
The variables in this study were: sex (female and male); age group (60|-79 and 80 years or more); marital status (with partner, without partner); education: (without, with); living arrangement (lives with someone, lives alone); individual monthly income (<1; ≥1); indicative of the presence of depressive symptoms (yes, no); number of self-reported morbidities (none; 1 │-│4, 5 or more); self-perceived health (negative, positive); basic activities of daily living (dependent, independent); instrumental activities of daily living (total/partial dependent, independent); AADL (lower participation, greater participation); and resilience (average scores).
Statistical analyzes were performed in Statistica version 10, SPSS version 24 and Analysis of Moment Structures (AMOS) version 24.
In order to compare sociodemographic and health variables between older adults who died and survivors, the non-parametric Wilcoxon test was applied, with an assumption previously assessed by the Kolmogorov-Smirnov normality test and differences with p<0.05 considered significant.
To analyze resilience (2018) as a predictor of mortality (2022), unadjusted and adjusted Cox proportional hazards models were performed, estimating Risk Ratios (RR) and 95% Confidence Interval (CI). For the adjusted model, variables that showed significance (p<0.05) in bivariate analysis were considered, such as sex, number of morbidities, self-perceived health, depressive symptoms and AADL. It is noteworthy that, in the linear regression analysis, the number of self-reported morbidities was dichotomized into 0 to 4, 5 or more.
From the variables included in Cox regression analysis, a structural equation modeling analysis model was constructed to identify the direct and indirect associations of resilience with mortality. The parameters were estimated using the Asymptotically Distribution Free method. Unadjusted and adjusted Cox proportional hazards models were performed, estimating RR and 95%CI. For the adjusted model, variables that showed significance (p<0.05) in bivariate analysis were considered.
Figure 1 presents the explanatory conceptual model to identify the direct and indirect associations of resilience with mortality.
Hypothetical conceptual model of the relationship between resilience and death. Uberaba, MG, Brazil, 2022. Caption: SPH: self-perceived health; AADL: advanced activities of daily living. Sex: 0 =female 1=male; Death: 0=No; 1=Yes
Data collection for 2018 and 2022 was approved by the Universidade Federal do Triângulo Mineiro Research Ethics Committee (REC) within the ethical standards of Resolution 466/12 of the Ministry of Health.
RESULTS
Among the 791 older adults participating in the study in 2018 (baseline), 12.6% (n=100) corresponded to deaths, with an average follow-up period of 57.5 ± 11.8 months (2018-2022).
The comparison of sociodemographic and health variables identified a higher proportion of older male adults (p=0.023), who had five or more diseases (p=0.043), with the presence of depressive symptoms (p<0.001), negative self-perceived health (p<0.001), lower participation in AADL (p=0.004) and lower resilience score (p<0.001) among those who died compared to survivors (Table 1).
It was found in the unadjusted Cox regression model that the highest resilience score reduced the risk of all-cause mortality. After adjustment (sex, number of diseases, depressive symptoms, self-perceived health and AADL), the highest resilience score remained associated, being considered a predictor of lower mortality (RR: 0.98; 95%CI: 0.97-0 .99; p=0.036) (Table 2).
Based on the variables included in Cox regression analysis (sex, number of morbidities, self-perceived health, depressive symptoms and AADL), the model was created to verify direct and indirect associations between resilience and mortality, as shown in Figure 1, presented previously. The model presented satisfactory goodness-of-fit indices, namely: χ2(gl=5)=7.8; p=0.167; CFI=0.992; GFI=0.998; TLI=0.966; RMSEA=0.027.
It was observed that the highest resilience score (β=-0.09; p=0.025) in 2018 was directly associated with lower mortality in 2022. Males, in turn, (β=0.12; p= 0.001), were directly associated with higher mortality (Table 3). It was found that the highest resilience score mediated by greater participation in AADL (β=-0.02; p<0.05) and positive self-perceived health (β=-0.05; p<0.05) was associated with lower mortality (Table 3).
Direct and indirect standardized coefficients for variables associated with mortality in older adults, Uberaba, 2018-2022
DISCUSSION
Throughout follow-up, it was observed that older adult males, with five or more illnesses, depressive symptoms, negative self-perceived health, less participation in AADL and a lower resilience score died at a higher rate when compared to survivors. Furthermore, the higher resilience score reduced the risk of mortality from all causes. On the other hand, a lower resilience score and being male were directly associated with higher mortality. The “greater participation in AADL” and “positive self-perceived health” variables mediated the relationship between higher resilience scores and lower mortality.
In this study, males had, proportionally, higher mortality throughout follow-up. In most populations, men experience greater mortality than women at each age, and the reasons for these differences have biological and non-biological origins20.
Culturally, males tend to adopt a riskier lifestyle combined with harmful behaviors, such as alcohol and tobacco consumption, inadequate eating habits, reckless driving and involvement in situations that may involve damage to their health or integrity as a worker. Furthermore, they are also more prone to curative practices than disease prevention, because there are several stereotypes related to gender in health care20.
Therefore, in general, men do not show the same adherence experienced by women when faced with the need to change behavior, considering that chronic non-communicable diseases depend on specific treatments and individual actions to promote health and prevent diseases. This behavioral trend has led to greater mortality from cardiovascular causes among men. This would be one of the reasons that would explain the disadvantage of males in the context of mortality20.
As for the number of diseases, according to the findings in this research, the study found that polymorbidity in older adults can cause serious losses, including greater risks of death and functional decline, in addition to impacting the reduction of life expectancy21. From this perspective, it was observed that a higher resilience score can contribute as a potential defense against the deleterious effects of multimorbidity, including symptom burden and functional decline11.
Research with older adults in the community, using the same depression indicator scale, found similar data to this research, in which the majority of older adults presented an absence of depressive symptoms22. However, among those who died, the indication of depression was present, denoting the need to assess this variable early in primary care services.
Negative self-perceived health was, proportionally, greater among older adults who died. This finding is in line with the literature review study, which identified an association between the presence of chronic conditions and self-rated health in more than half of the articles included in the research11. Thus, as the number of chronic conditions increases, self-perceived health can become negative11 and result in death, as observed in the results of this research.
In relation to AADLs, which cover voluntary recreational, occupational and social activities23, it is highlighted that difficulties in carrying them out do not mean direct functional loss, but may suggest a risk situation for future losses23. The results of this work highlight this fact, in which the lowest participation in AADL was greater among those who died compared to survivors. Supporting the findings of this study, research with older Chinese adults identified that limitations in AADL, as a result of chronic conditions or other health problems, was a factor that influenced self-perceived health24, highlighting the need to identify and act, if necessary, on these variables in primary care for older adults.
With the aforementioned results of this study, it was possible to observe the characteristics of older adults who died and how these variables are related, being able to act synergistically and contribute to the outcome. From this perspective, health actions that make early diagnosis, encourage health self-care, social interaction and preservation of independence are essential to delay adverse outcomes.
Regarding the findings related to the higher resilience score, which reduced the risk of mortality among older adults, throughout the follow-up, they converge with longitudinal research carried out in China25. The authors highlight that the protective effects of resilience on mortality risk still remained significant, even after controlling for the initial health status of older adults21. A study conducted in Italy, with the general population, also found that the highest resilience score reduced the risk of mortality from all causes by 20%10. Therefore, it is possible that resilience may have independent effects on mortality risk, considering that resilient older adults are more likely to experience positive emotions, promoting health and longevity25. Furthermore, positive acceptance of changes in the face of adversity was associated with lower mortality from all causes10.
The reduction in the risk of mortality from all causes related to the higher resilience score, obtained in this study, reflects a positive reaction of individuals in the face of challenges, which provides a promising perspective in relation to health26. Thus, individuals are able to better face adverse situations, even when they pose a potential risk to their health, mitigating mortality26.
The lower resilience score and males were directly associated with higher mortality, denoting the relevance of monitoring older adults measuring resilience, making possible interventions, in addition to having a peculiar look at the differences between genders. It is worth noting that gender is a considerable factor in individuals’ responses to stressful situations. Thus, men and women may present different vulnerabilities to adversity as a result of their social roles and also socioeconomic factors27.
AADL and positive self-perceived health mediated the relationship between higher resilience scores and lower mortality. From this perspective, research with older adults identified that, although limitations may be present as a result of chronic conditions or other health problems, the ability to engage in AADL was fundamental to positive self-perceived health24. Thus, the positive role of resilience in better self-perceived health influenced the lower number of deaths24.
It is worth noting that, in the analysis of the variables with the outcome, we found different magnitudes, even though they are all significant. Males and self-perceived health were the variables that had the greatest impact on mortality, whereas AADL and resilience had the least impact. Such findings for these participants should be further explored in other studies with older adults, with the aim of building knowledge beyond the variables that impact mortality, but to what extent this happens.
The findings of this investigation can contribute to the management of health services and clinical practice, considering that they can support multidimensional interventions aimed at increasing older adults’ resilience and achieving better outcomes, while remaining active and independent members of their communities24. In this context, resilience represents one of the possible ways for health professionals to shift the emphasis from the negativity of diseases and declines to older adults’ potential24.
As for the limitations of this study, they are related to the second data collection that took place by telephone, due to the pandemic period, with unanswered calls and invalid numbers. It is noteworthy that this study covered a period of four years, highlighting the short-term results of the effects of resilience on mortality. Therefore, new research must be carried out, aiming to identify the effects of long-term resilience as well as possible adaptive coping strategies.
CONCLUSION
The results of this study provided evidence to support that higher resilience score was associated with reduced risk of mortality. It also identified a higher proportion of older male adults who had five or more diseases, with the presence of depressive symptoms, negative self-perceived health, less participation in AADL and a lower resilience score among those who died compared to survivors. A higher resilience score and male sex were directly associated with lower mortality. The highest resilience score, mediated by greater participation in AADL and positive self-perceived health, was associated with lower mortality.
This research provides information that contributes to the scientific knowledge older adults’ resilience and can support new studies and clinical practice with a view to contributing to actions aimed at postponing mortality among older adults.
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NOTES
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ORIGIN OF THE ARTICLE
Extracted from the thesis “Preditores de resiliência e mortalidade em older adults: análise de equação estrutural”, presented to the Graduate Program in Health Care, Universidade Federal do Triângulo Mineiro, in 2023.
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FUNDING INFORMATION
This study was funded by the Brazilian National Council for Scientific and Technological Development (CNPq - Conselho Nacional de Desenvolvimento Científico e Tecnológico). Process 371218/2019-5.
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APPROVAL OF ETHICS COMMITTEE IN RESEARCH
Approved by the Universidade Federal do Triângulo Mineiro Research Ethics Committee, Opinions 2053520 (2017) and 4591597 (2021), Certificate of Presentation for Ethical Consideration (Certificado de Apresentação para Apreciação Ética) 65885617.8.0000.5154 (2017) and 43816721.0.0000.5154 (2021).
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TRANSLATED BY
Letícia Belasco.
Edited by
Publication Dates
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Publication in this collection
11 Nov 2024 -
Date of issue
2024
History
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Received
03 Apr 2024 -
Accepted
28 June 2024
