Abstract
To explore the relationship between depression symptoms, frailty, and walking ability in Chinese elderly people, and to provide new evidence for research on the prevention and treatment of depression in Chinese elderly people. The data of this study is sourced from the 2018 CHARLS data (China Health and Retirement Longitudinal Study). Z-test, logistic regression, and linear stratified regression were used to analyze the walking ability, frailty, and depressive symptoms of 2927 participants. Good walking ability and non frailty were significantly negatively correlated with depression symptoms in the elderly (P < .05). This important negative association persists even after adjusting for demographic, health condition, and lifestyle factors. (P < .05). Elderly women are at a higher risk of developing depression than men, while elderly people with good walking ability and no frailty are at a lower risk of developing depression. At the same time, elderly people with disabilities, hypertension, arthritis, and low levels of physical activity are more likely to experience depressive symptoms. It is recommended that elderly people pay attention to maintaining walking ability and avoiding frailty to reduce the risk of depression.
Keywords: depression, elderly people, frailty, relationship, walking ability
1. Introduction
In recent years, the issue of depression in the elderly has received widespread attention.[1] With the intensification of China’s aging population, this issue has increasingly become a focus of attention in society and the medical community.[2] Research shows that the incidence rate of depression in the elderly is higher than that in the young, especially in the elderly over 60 years old. The incidence rate of depression may continue to rise with age.[3] The symptoms of depression in elderly people may be different from those in young people.[4] For example, elderly people may be more prone to symptoms such as anxiety, insomnia, and pain. In addition, elderly patients with depression may be more prone to cognitive impairment and decreased quality of life.[5] Research has found that factors such as genetics, gender, marital status, chronic diseases, retirement, social support, education level, and a history of depression may all increase the risk of depression in elderly people.[6,7] There are also studies indicating that depression in the elderly is related to frailty. Elderly frailty refers to the gradual decline in physical, psychological, and social functions of the elderly due to various reasons, such as aging, chronic diseases, disabilities, malnutrition, etc.[8,9]
The prevalence of frailty among elderly people is on the rise globally.[10] Frailty can cause despair, a worse quality of life, more hospital admissions, more deaths, and psychiatric issues.[11] There is a close relationship between depression and frailty in the elderly. Depression and frailty may be related to biological factors such as genetics, age, gender, and chronic diseases.[12] These factors may interact with each other, leading to the simultaneous occurrence of depression and frailty. Frailty can affect the mental health of elderly people, such as reducing self-esteem, anxiety, and depression.[13] Frailty can also increase the risk of death in elderly people, which may further exacerbate the symptoms of depression.[14] Numerous studies indicate a negative correlation between excellent capacity for walking and the risk for depressive disorders in the elderly, and low walking ability being associated with a higher risk of depression than strong walking ability.[15] Another study suggests that elderly people with good walking ability also maintain good physical and mental health.[16] The decline in walking ability may be a manifestation of the decline in physical health. Physical health problems may lead to depression, because people may feel distressed, helpless or lose confidence in life due to health problems.[17] The decline of walking ability may lead to the reduction of people’s social activities, which may lead to depression, because people may feel lonely or isolated.[18] However, there is scant empirical data about the association between depression and old frailty and walking capacity, and the scientific rigor of different studies differs. The purpose of this study is to explore the relationship between the walking ability of the elderly and the symptoms of frailty and depression after adjusting Demographics variables, health status and lifestyle.
2. Methods
2.1. Participants and data
Peking University has launched a significant transdisciplinary project called China Health and Retirement Longitudinal Study (CHARLS).[19] The goal is to gather information on the population, physical and mental health, personal and family economic condition, medical services, and insurance of the elderly in China in order to study the country’s population’s aging situation and advance transdisciplinarity on aging. Data from CHARLS 2018 were used in our analysis. The Peking University in China’s CHARLS database houses all of the data that was gathered during CHARLS. All data can be found in http://charls.pku.edu.cn. This study was approved by the Ethics Review Committee of Anshan Normal University, China.
2.2. Variables
2.2.1. Demographic, health status and lifestyle variables.
Gender (male or female), age (50–59 years old, 60–69 years old, 70–79 years old, 80–89 years old, or over 90 years old), registered residence registration type (urban or rural), education level (below high school or above) and widowhood (yes or no) are demographic factors. The health status includes the presence of hypertension, hyperlipidemia, memory impairment, stroke, asthma, arthritis, negative emotions, and disability, and lifestyle includes high or low levels of physical activity. The physical activity (PA) level was calculated using the International Physical Activity Questionnaire.[20,21] A total of 23 Metabolic Equivalent of Energy hours per week (high physical activity) or 23 Metabolic Equivalent of Energy hours per week (low physical activity) were used to calculate the weekly amount of PA. The data of health status variables is obtained through self-report by participants.
2.2.2. Frailty.
FRAIL scale: the International Geriatric Nutrition Society proposed the FRAIL scale,[22] which also includes 5 items:
Fatigue sensation
Resistance: It feels difficult to climb the stairs one level
Free movement descent: unable to walk for 1 block
Coexistence of multiple diseases: ≥ 5
Weight loss: Weight loss > 5.0% within 1 year.
Criteria: Elderly individuals with 3 or more criteria are rated as frail, those with 1 or 2 criteria are rated as pre frail, and those with 0 criteria are healthy elderly individuals who are not frail
2.2.3. Walking ability.
Participants’ self-reports were used to determine their capacity for a 1-kilometer walk as well as their current state of self-assessed health.
2.2.4. Depression.
The severity of depression in elderly and elderly people was evaluated by the CES-D short form. The CES-D scale has a high level of validity and reliability in investigations of the Chinese population, according to Radloff (1977).[23] The CHARLS questionnaire’s short CES-D scale consists of the following 10 questions: I stress about things that don’t seem to matter, I have problems concentrating when I’m doing things, I feel melancholy, I believe that everything is very tough, I’m optimistic about the future, I’m terrified, I struggle to fall asleep, I’m joyful, I’m lonely, and I think I can’t continue with my life. Each question’s expression of grief receives a score between 0 and 3, ranging from low to high; the scores of 5 to 8 are considered to be quite high; the scores of 5 and 8 are calculated backwards. Participants are considered “depressed” if their total score is 10 or above. A total score of less than 10 points was obtained, and participants were classified as’ not depressed ‘or below.
2.3. Statistical analysis
Each statistical explanation includes variables. The factors affecting walking ability, frailty, and depressive symptoms were tested using multivariate logistic regression analysis. Using depressive symptoms as the dependent variable and walking ability and frailty as independent variables, calculate the correlation between walking ability and vulnerability and the probability of developing depressive symptoms. Use multi-layer linear regression analysis to determine the association between depression and walking ability and frailty, as well as the association between depression and walking ability and frailty after controlling for demographic variables, health status variables, and lifestyle variables. Model 1 looked into the connection between depressed symptoms, frailty, and the capacity to walk. Based on the modifications made in Mode 1, Mode 2 adjusted the demographic variables (gender, age, registered house type, education level, and widowhood situation). Model 3 made adjustments for lifestyle and health status factors (asthma, arthritis, emotional distress, disability, hypertension, memory impairment, hyperlipidemia, stroke, and physical activity) on the basis of Model 2. For all statistical analyses, P < .05 was considered statistically significant. All statistical analyses were performed using IBM SPSS Statistics 27.0 software (IBM SPSS Inc., Chicago, IL).
3. Results
3.1. Demographic characteristic
A total of 2927 participants were included in this study. Among them, 1148 men (49.5%) and 1179 women (50.5%) passed the Z-test, and there was no significant difference between the sexes of the participants (P = .567). Descriptive statistics found that 74.9% of participants were able to walk 1 kilometer. 25.9% of participants are in a frail state. 33.7% of subjects reported having depressed symptoms. Participants who are 50 to 59, 60 to 69, 70 to 79, 80 to 89, and 90 and more make up, respectively, 4.7%, 15.8%, 37.9%, 36.7%, and 4.9% of the total. Urban registered residence makes up 22.2% of participants’ registered dwelling types. Culturally speaking, 80.8% of participants have not completed high school. The percentage of widows among the participants was 11.1%. 11.9% of individuals had high blood pressure, 12.7% had high cholesterol, 2.4% had memory problems, 3.7% had impairments, 6.3% had strokes, 1.8% had asthma, 7.2% had arthritic conditions and 1.0% had negative emotions. In terms of lifestyle, 47.7% of participants have a high level of physical activity. The Z-test showed statistical differences among all variables except for gender (P < .05) (Fig. 1; Table 1).
Figure 1.
A total of 19752 participants participated in the 2018 China Health and Retirement Longitudinal Study (Charls). 16242 people were excluded because of incomplete information on walking ability, frailty, depression and others variables, leaving 3510 people. 3510 did not include 583 individuals since they were under the age of 50. Finally, the study’s final 2927 subjects were added.
Table 1.
Characteristics of middle-aged and elderly participants of the CHARLS in 2018.
| Number of participants | % | Z | P | ||
|---|---|---|---|---|---|
| Gender | Male | 1148 | 49.5 | ||
| Female | 1179 | 50.5 | 0.573 | .567 | |
| Age (yr) | 50–59 | 138 | 4.7 | ||
| 60–69 | 462 | 15.8 | |||
| 70–79 | 1110 | 37.9 | |||
| 80–89 | 1074 | 36.7 | |||
| ≥90 | 143 | 4.9 | −48.815 | .000 | |
| Location of residence | City | 651 | 22.2 | ||
| Rural | 2276 | 77.8 | 30.036 | .000 | |
| Degree of education | Junior high school and below | 2365 | 80.8 | ||
| High school and above | 562 | 19.2 | −33.326 | .000 | |
| Widowed | Yes | 362 | 11.1 | ||
| No | 2601 | 88.9 | 42.050 | .000 | |
| Self-rated health status | Good | 713 | 24.4 | ||
| Bad | 2214 | 75.6 | 27.744 | .000 | |
| Bad mood | Yes | 30 | 1.0 | ||
| No | 2195 | 99.0 | 52.974 | .000 | |
| Hypertension | Yes | 347 | 11.9 | ||
| No | 2580 | 88.1 | 41.274 | .000 | |
| Hyperlipidemia | Yes | 372 | 12.7 | ||
| No | 2555 | 87.3 | 40.350 | .000 | |
| Frailty | Yes | 759 | 25.9 | ||
| No | 2168 | 74.1 | 26.044 | .000 | |
| Memory disease | Yes | 70 | 2.4 | ||
| No | 2855 | 97.6 | 51.495 | .000 | |
| Physical disability | Yes | 107 | 3.7 | ||
| No | 2820 | 96.3 | 50.146 | .000 | |
| Arthritis | Yes | 211 | 7.2 | ||
| No | 2712 | 92.8 | 46.259 | .000 | |
| Asthma | Yes | 52 | 1.8 | ||
| No | 2873 | 98.2 | 52.160 | .000 | |
| Stroke | Yes | 183 | 6.3 | ||
| No | 2744 | 93.7 | 47.337 | .000 | |
| Walk one kilometer | Yes | 2325 | 79.4 | ||
| No | 602 | 20.6 | −31.847 | .000 | |
| Depression | Yes | 985 | 33.7 | ||
| No | 1942 | 66.3 | 17.689 | .000 | |
| Physical activity | High | 1395 | 47.7 | ||
| Low | 1532 | 52.3 | 2.532 | .011 | |
3.2. Analysis of influencing factors of walking ability
After using logistic regression, we found that age, education level, vulnerability, disability, hypertension, stroke, emotional distress, arthritis, physical activity, and depression were significantly correlated with participants’ walking ability (P < .05). As age increases (OR = 1.965), the walking ability of participants significantly decreases. Participants with low educational level (OR = 1.470) had significantly poorer walking ability. Participants with weakness (OR = 0.457) have poor walking ability. Participants with disabilities (OR = 2.073), hypertension (OR = 1.330), stroke (OR = 1.970), and arthritis (OR = 0.498) had significantly poorer walking ability. Furthermore, we found that bad mood (OR = 4.023), lower physical activity (OR = 0.521), and the poor walking ability of participants with depression (OR = 1.627) (Table 2).
Table 2.
Analysis of influencing factors of walking ability.
| Walking ability | B | SE | Wald | P | OR | 95% CI | ||
|---|---|---|---|---|---|---|---|---|
| Lower | Upper | |||||||
| Yes | Gender | 0.077 | 0.103 | 0.559 | .455 | 1.080 | 0.883 | 1.322 |
| Age (yr) | 0.676 | 0.059 | 130.100 | .000 | 1.965 | 1.750 | 2.207 | |
| Location of residence | 0.068 | 0.124 | 0.304 | .581 | 1.071 | 0.840 | 1.366 | |
| Degree of education | 0.385 | 0.144 | 7.167 | .007 | 1.470 | 1.109 | 1.950 | |
| Widowed | 0.171 | 0.150 | 1.304 | .253 | 1.186 | 0.885 | 1.591 | |
| Frailty | −0.783 | 0.138 | 31.961 | .000 | 0.457 | 0.348 | 0.600 | |
| Physical disability | 0.729 | 0.228 | 10.204 | .001 | 2.073 | 1.325 | 3.242 | |
| Hypertension | 0.285 | 0.149 | 3.677 | .045 | 1.330 | 0.994 | 1.781 | |
| Hyperlipemia | −0.095 | 0.151 | 0.394 | .530 | 0.909 | 0.676 | 1.223 | |
| Diabetes | −0.274 | 0.196 | 1.949 | .163 | 0.761 | 0.518 | 1.117 | |
| Stroke | 0.678 | 0.184 | 13.635 | .000 | 1.970 | 1.374 | 2.823 | |
| Bad mood | 1.392 | 0.404 | 11.857 | .001 | 4.023 | 1.822 | 8.886 | |
| Memory disease | 0.380 | 0.283 | 1.802 | .179 | 1.463 | 0.839 | 2.549 | |
| Arthritis | −0.696 | 0.220 | 9.986 | .002 | 0.498 | 0.324 | 0.768 | |
| Asthma | −0.474 | 0.392 | 1.464 | .226 | 0.622 | 0.289 | 1.342 | |
| Physical activity | −0.652 | 0.113 | 33.286 | .000 | 0.521 | 0.418 | 0.650 | |
| Depression | 0.487 | 0.109 | 20.033 | .000 | 1.627 | 1.315 | 2.014 | |
Bold indicates P < 0.05.
3.3. Analysis of influencing factors of frailty
After using logistic regression, we found that age, widowhood, disability, hypertension, hyperlipidemia, stroke, memory disorders, arthritis, asthma, physical activity, walking ability, and depression were significantly correlated with participants’ frailty (P < .05). Participants who are elderly (OR = 0.588) and widowed (OR = 1.517) are more susceptible to frailty. Participants with disabilities (OR = 0.309), hypertension (OR = 0.577), hyperlipidemia (OR = 0.652), stroke (OR = 0.222), memory disorders (OR = 0.312), arthritis (OR = 0.522), and asthma (OR = 0.317) are more likely to suffer from frailty. Furthermore, we found that participants with memory disorders (OR = 0.312), low physical activity (OR = 1.112), poor walking ability (OR = 2.143), and depression (OR = 1.212) are more likely to suffer from frailty (Table 3).
Table 3.
Influencing factors of frailty among elderly participants in CHARLS in 2018.
| Frailty | B | SE | Wald | P | OR | 95% CI | ||
|---|---|---|---|---|---|---|---|---|
| Lower | Upper | |||||||
| Yes | Gender | 0.010 | 0.093 | 0.012 | .913 | 1.010 | 0.842 | 1.213 |
| Age (yr) | −0.531 | 0.197 | 7.241 | .007 | 0.588 | 0.399 | 0.866 | |
| Location of residence | 0.087 | 0.117 | 0.547 | .460 | 1.091 | 0.867 | 1.372 | |
| Degree of education | −0.136 | 0.112 | 1.485 | .223 | 0.872 | 0.700 | 1.087 | |
| Widowed | 0.417 | 0.145 | 8.297 | .004 | 1.517 | 1.142 | 2.014 | |
| Physical disability | −1.173 | 0.402 | 8.510 | .004 | 0.309 | 0.141 | 0.680 | |
| Hypertension | −0.549 | 0.229 | 5.777 | .016 | 0.577 | 0.369 | 0.904 | |
| Hyperlipemia | −0.428 | 0.158 | 7.347 | .007 | 0.652 | 0.479 | 0.888 | |
| Stroke | −1.507 | 0.350 | 18.488 | .000 | 0.222 | 0.111 | 0.440 | |
| Bad mood | −0.991 | 0.748 | 1.757 | .185 | 0.371 | 0.086 | 1.607 | |
| Memory disease | −1.165 | 0.530 | 4.824 | .028 | 0.312 | 0.110 | 0.882 | |
| Arthritis | −0.650 | 0.203 | 10.297 | .001 | 0.522 | 0.351 | 0.777 | |
| Asthma | −1.149 | 0.532 | 4.672 | .031 | 0.317 | 0.112 | 0.898 | |
| Physical activity | 0.106 | 0.099 | 1.147 | .028 | 1.112 | 0.916 | 1.351 | |
| Walking ability | 0.762 | 0.140 | 29.814 | .000 | 2.143 | 1.630 | 2.817 | |
| Depression | 0.192 | 0.107 | 3.233 | .042 | 1.212 | 0.983 | 1.495 | |
Bold indicates P < 0.05.
3.4. Analysis of influencing factors of depression
After using logistic regression, we found that gender, age, disability, hypertension, arthritis, physical activity level, walking ability, and fatigue were associated with depression (P < .05). Compared to men, women (OR = 0.541) are more likely to experience depressive symptoms. As age increases (OR = 0.445), the risk of participants experiencing depressive symptoms increases. Participants with hypertension (OR = 0.577), disability (OR = 0.531), and arthritis (OR = 1.546) have a significantly higher risk of depression. Furthermore, we found that participants who had high levels of physical activity (OR = 0.171), good walking ability (OR = 0.639), and did not suffer from fatigue (OR = 1.240) had a significantly reduced risk of depression (Table 4).
Table 4.
Analysis of influencing factors of depression among elderly participants in CHARLS in 2018.
| Depression | B | SE | Wald | P | OR | 95% CI | ||
|---|---|---|---|---|---|---|---|---|
| Lower | Upper | |||||||
| yes | Gender | −0.614 | 0.093 | 43.529 | .000 | 0.541 | 0.451 | 0.650 |
| Age (yr) | −0.809 | 0.209 | 15.011 | .000 | 0.445 | 0.296 | 0.670 | |
| Location of residence | −0.137 | 0.123 | 1.238 | .266 | 0.872 | 0.686 | 1.110 | |
| Degree of education | −0.118 | 0.118 | 1.008 | .315 | 0.888 | 0.705 | 1.119 | |
| WIDOWED | −0.155 | 0.148 | 1.101 | .294 | 0.856 | 0.640 | 1.144 | |
| Physical disability | −0.634 | 0.242 | 6.834 | .009 | 0.531 | 0.330 | 0.853 | |
| Hypertension | −0.550 | 0.171 | 10.381 | .001 | 0.577 | 0.413 | 0.806 | |
| Hyperlipemia | 0.208 | 0.135 | 2.363 | .124 | 1.231 | 0.944 | 1.606 | |
| Stroke | −0.006 | 0.185 | .001 | .974 | 0.994 | 0.692 | 1.427 | |
| Bad mood | −0.424 | 0.423 | 1.005 | .316 | 0.654 | 0.286 | 1.499 | |
| Memory disease | 0.189 | 0.275 | .473 | .492 | 1.208 | 0.704 | 2.074 | |
| Arthritis | 0.435 | 0.172 | 6.378 | .012 | 1.546 | 1.102 | 2.167 | |
| Asthma | 0.251 | 0.328 | .585 | .444 | 1.285 | 0.676 | 2.442 | |
| Physical activity | −1.765 | 0.100 | 313.636 | .000 | 0.171 | 0.141 | 0.208 | |
| Walking ability | −0.448 | 0.112 | 16.039 | .000 | 0.639 | 0.513 | 0.796 | |
| Frailty | 0.215 | 0.103 | 4.342 | .037 | 1.240 | 1.013 | 1.517 | |
Bold indicates P < 0.05.
3.5. Analysis of linear hierarchical regression models between participants’ frailty, walking ability and depressive symptoms
Model 1 shows a significant correlation between walking ability and fatigue and depressive symptoms (P < .05). Model 2 adjusted the Demographics characteristic variables (gender, registered residence type, education level, age, widowhood) on the basis of model 1, and model 3 adjusted the health status and lifestyle characteristics (asthma, arthritis, bad mood, disability, high blood pressure, memory disease, hyperlipidemia, stroke, sports activities) on the basis of model 2, and the results were still significant (P < .05) (Table 5). In addition, we found a significant negative correlation between non frailty and good walking ability in the elderly and depressive symptoms. The significant negative association persists even after adjusting for demographic, health condition, and lifestyle factors.
Table 5.
Analysis of linear hierarchical regression models between participants’ frailty, walking ability and depressive symptoms.
| Model | R | R 2 | Adjusted R2 | Variation statistics | |
|---|---|---|---|---|---|
| F variation | P | ||||
| 1 | 0.194* | 0.038 | 0.037 | 57.093 | .000 |
| 2 | 0.293† | 0.086 | 0.084 | 39.015 | .000 |
| 3 | 0.442‡ | 0.196 | 0.191 | 41.478 | .000 |
Predictor variable: walking 1 kilometer, frailty.
Predictive variables: walking 1 kilometer, frailty, gender, household registration type, education level, widowhood, age.
Predictor variables: walking 1 kilometer, frailty, gender, registered permanent residence type, education level, widowhood, age, asthma, arthritis, poor mood, disability, hypertension, memory disease, hyperlipidemia, stroke, physical activity.
4. Discussion
In this study, the influences of walking ability, fragility, and depression symptoms were examined in connection to walking ability, fragility, and depressive symptoms in senior adults. This study discovered a substantial negative correlation between senior depressed symptoms and high walking abilities and no frailty. This strong negative connection persisted even after controlling for demographic, health-related, and lifestyle factors. The findings of our study suggest that frailty can increase the risk of depressive symptoms in middle-aged and elderly people. The percentage of elderly people with frailty (25.9%) is lower than the percentage of elderly people without frailty (74.1%), and the risk of depressive symptoms in frailty is significantly higher than that in non-fragility. This result is supported by a previous study conducted by Sang et al.[24] Sang et al used a two-way 2 sample Mendelian randomization study to study the causal relationship between depression and frailty. The results showed that univariate analysis showed that depression was positively correlated with the risk of frailty. After adjusting for 3 potential confounding factors, a positive correlation between depression and frailty still exists. Ji et al[25] explored the relationship and age differences between frailty and depression in the elderly. They recruited 1789 community elderly people from the eastern region of China. Physical weakness and depressive symptoms were evaluated using the frailty phenotype and the 5-item Elderly Depression Scale, respectively. The results showed that stratified multiple linear regression analysis showed a significant correlation between frailty and depressive symptoms, and there was a significant interaction between age and frailty. Alexandra et al[26] conducted a retrospective study to investigate the relationship between depression and frailty in the elderly population. The results showed that the prevalence of depression symptoms in GDS-15 screening was 66.7%, and the degree of depression in women was higher than that in men. In addition, a significant relationship was observed between depression and dependence on daily activities. This study demonstrates the connection between frailty and depression, one of which is another risk factor for development. Due to high medical costs, insufficient understanding of this issue and inadequate diagnosis of these diseases are important public health issues. Therefore, there is an urgent need for active primary prevention in order to diagnose weakness and depression in the early stages, improve the quality of life of the elderly, and successfully age. Cristina et al[27] explored whether depression contributes to the occurrence of frailty syndrome, and vice versa, or whether the 2 coexist independently in the same individual. The results indicate that depression and weakness occur in a considerable proportion of frail elderly people, and there is a significant causal relationship between these 2 syndromes. According to the aforementioned findings and the outcomes of our investigation, we think there is a substantial inverse relationship between senior frailty and depressive symptoms. To lessen the frailty of the aged, which lessens their depression and improves their mental health, it is vital to adopt comprehensive policies and health management measures. Therefore, for the problems of frailty and depression in the elderly, it is necessary to comprehensively evaluate their health, mental state, and cognitive function, and develop corresponding treatment plans. This usually includes medication, psychotherapy, lifestyle adjustments, and exercise interventions.
Overall, our study’s findings show that older adults who can walk well have a higher percentage than those who can’t (79.4% vs 20.6%), and the number of depressive symptoms is much lower in senior individuals with strong walking ability than it is in those with poor mobility, suggesting that good walking capacity can lessen the risk of depressive symptoms in elderly individuals. An earlier investigation by the Gao et al[28] provides evidence in favor of this conclusion. To examine the connection between walking difficulties and visual impairment, depression, and cognitive function in the elderly, they recruited 1489 old Americans aged 60 and above. The association between walking difficulty and visual impairment, depression, and cognitive function was examined using a multivariate logistical regression model. According to the study’s findings, the prevalence of walking disorders among older Americans is strongly correlated with the number of walking problem indicators. It is important to diagnose depression in older adults who have problems walking. Charles et al[29] conducted cognitive tests, self reporting assessments of depression and fall self-efficacy, and walking assessments on 73 patients with Multiple sclerosis in a clinical nursing environment. The results indicate that walking ability is related to depressive symptoms, and the interaction between physical ability and psychological factors such as depression and self-efficacy may enhance understanding of walking performance in complex, real-world environments. The strength of a person’s muscles, the condition of their bones and joints, and their mental health are all fully reflected in their ability to walk.[30] The ability of elderly adults to walk can be improved by high-intensity physical activity. Depression risk can be lowered by physical activity.[31] The inverse relationship between depression and strong walking ability may be due to these variables. Our work serves as a guide for developing tailored, efficient therapies for depression in middle-aged and elderly patients. The study by Mobily et al[32] also supports the conclusions of this study. They developed an explanatory model for the relationship between exercise and depression using rural elderly people aged 65 or above. 2084 subjects with complete data, valid information about depressive symptoms, and the ability to walk in small rooms were divided into 2 cohort groups at baseline: the group with fewer depressive symptoms and the group with more depressive symptoms. During the 3-year follow-up, a logistic regression model was established using walking status, Demographics variables and chronic health status to predict the depressive symptoms of this population. Consistent with previous studies using mixed age groups, physical activity is negatively correlated with depressive symptoms, thanks to daily walking. Elderly people should improve their walking ability by improving their physical fitness, thereby reducing their risk of depression.
The outcomes of our model also quantify the association between walking capacity, fatty status, and depressed symptoms. These variables include demographic data, physical and mental health traits, and other variables. This study indicated that older women had a greater risk of depression than older males, which is consistent with the earlier study by Jang et al.[33] They used a community sample of 230 elderly Korean American immigrants from Florida to investigate gender differences in depressive symptoms. The results showed that women scored higher than men in terms of depressive symptoms. In a stratified regression model, women and those with more chronic diseases, more severe functional disabilities, and lower sense of control were found to have more depressive symptoms. The mental health status of elderly women is particularly at risk of decline. The mental health of middle-aged and older women should be taken into consideration, and suitable prevention and treatment measures should be developed in order to better their mental health.[34] Aging is a multifactorial process that affects the human body at various levels and leads to biological and psychological changes.[35] This study found that as age increases, the risk of depression symptoms increases in elderly people. A study suggests that a lower subjective age is associated with better physical and mental health, cognitive function, happiness, and life satisfaction.[34] China is one of the countries with the most severe aging problem. We need to pay attention to the lives of the elderly from multiple aspects, and pay attention to the impact of aging on their mental health, such as providing sufficient social support, paying attention to their physical health, and encouraging them to participate in social activities.[36] At the same time, encouraging elderly people to maintain a positive mindset and optimistic emotions, learn to face difficulties and challenges in life, and also help prevent depression.[36,37] Therefore, for people with decreased walking ability, family and friends should provide more care and support to help them maintain a good psychological state. Meanwhile, maintaining a healthy lifestyle and engaging in appropriate exercise may also help improve walking ability and alleviate depression.[38]
This study evaluated the impact of the health status of middle-aged and elderly people on depressive symptoms. We found that middle-aged and elderly people with hypertension, disability, weakness, and arthritis are more likely to suffer from depression, and their walking ability is also poor. Juxia et al[39] conducted a cross-sectional study in Northwestern China to explore the anxiety and depression of patients with pulmonary hypertension. They used Self Rating Anxiety Scale and Self Rating Depression Scale to assess 106 patients with pulmonary hypertension in Northwestern China. The results showed that the depression symptoms of the selected patients were particularly severe (70.09%), with anxiety being 17.55%, and the shorter the 6-minute walking distance (P < .01), the higher the anxiety and depression scores. They suggest early detection of mental health issues such as depression and anxiety in patients with pulmonary hypertension. At the same time, intervention measures should be taken to address these issues to improve the psychological status of these patients. Verhaak et al[40] conducted a cross-sectional survey to explore the relationship between depression, disability, and physical illness in the elderly. The results indicate that disability and all its subscales are closely related to depression, and the relationship between people aged 60 to 69 and those over 70 is more close. The important aspects of disability that lead to depression are disability in terms of participation, self-care, and social activities. Ke et al[41] evaluated the bidirectional relationship between depression and arthritis in the middle-aged and elderly population in China. The results indicate that compared to non depressive patients, depressive patients have a significantly higher risk of developing arthritis, and the onset of depression increases the risk of developing arthritis. Borges et al[42] investigated the relationship between depression and frailty in elderly outpatient patients using different assessment tools. The results indicate that regardless of the evaluation tool used, depression and frailty in later life are related in a dose-dependent manner. Frailty elderly may face a variety of health problems, such as Chronic pain, arthritis, heart disease, etc. These health issues may lead to a decrease in quality of life and further exacerbate symptoms of depression. Elderly people should learn basic treatment and rehabilitation knowledge of diseases, have a correct understanding of diseases, and strengthen their ability to self-care. In order to reduce the association between elderly frailty and depression, family and society should give more attention and support, encourage elderly people to participate in social activities, maintain physical and mental health, and seek professional help in a timely manner.
In addition, this study shows that elderly people with high levels of physical activity have a significantly lower risk of developing depressive symptoms than those with low levels of physical activity. Elderly people with high levels of physical activity also have better walking ability than those with low levels of physical activity. McDowell et al[43] investigated the cross-sectional and prospective associations between different levels of moderate to severe physical activity and walking, depressive symptoms, and state. Participants aged ≥50 completed the International PA Questionnaire at baseline and the Epidemiological Research Center Depression Scale at baseline and 2 years later. The results indicate that. Moderate and high levels of physical activity are significantly associated with a lower probability of concurrent depression, and are significantly and non-significantly associated with a lower probability of occasional depression. The recommended level of physical activity and walking are significantly associated with a reduced risk of developing depression. Luciana et al[44] validated the relationship between anxiety and depression symptoms, physical exercise disorders, and walking ability in patients with intermittent claudication. They included 113 patients clinically diagnosed with intermittent claudication in the study. The patient received the clinical evaluation of the vascular surgeon, answered the Beck Depression Inventory, and the psychologist applied the Beck Anxiety Scale. The patient underwent a 6-minute test and reported their obstacles in physical activity practice in the questionnaire. The results showed that patients with depressive symptoms had shorter painless walking distance and total walking distance compared to patients without signs of depression. The painless walking distance and total walking distance between patients with and without anxiety symptoms are similar. Compared with patients without depressive symptoms, patients with moderate to severe depressive symptoms encountered more obstacles in physical activity practice. Seniors’ social interactions and emotions can be improved by PA, and positive emotions lower the chance of depression. These research support the findings of the present investigation.
There are currently few studies explaining the potential mechanisms underlying the relationship between walking ability, frailty, and depression. Based on our research findings, we speculate that: Physiological mechanisms: Decreased walking ability, weakness, and depression may have some common physiological changes, such as the nervous system, immune system, endocrine system, etc. These physiological changes may lead to mutual influence among the 3.[45] Psychological mechanisms: Decreased walking ability, frailty, and depression may share some psychological risk factors, such as negative perception of life and sensitivity to stress. These psychological factors may make individuals more likely to experience both frailty and depression simultaneously.[46] Social support: Social support is an important factor in protecting individual mental health. Lack of social support may increase the risk of decreased walking ability, frailty, and depression.[47] Comorbidity: Decreased walking ability, frailty, and depression may coexist in certain diseases, such as cardiovascular disease and cancer.[48] These diseases may cause physiological and psychological stress, leading to the occurrence of frailty and depression.[49] These mechanisms may not be independent, but may interact with each other in different individuals and situations. Analyzing the relationship between decreased walking ability, frailty, and depression can provide more effective interventions for the treatment and prevention of depression in the elderly.[50]
5. Conclusion and limitations
There is a significant correlation between walking ability, frailty, and depressive symptoms in the elderly, but research on walking ability, frailty, and depressive symptoms in the elderly in China is still in the preliminary exploration stage. In this study, elderly women had a higher risk of developing depression than men, while elderly people with good walking ability and no fatigue had a lower risk of developing depression. The likelihood of developing depressive symptoms is higher in older persons who have impairments, hypertension, arthritis, and poor levels of physical activity. The association between senior people’s walking capacity, frailty, and depressive symptoms is better understood thanks to this study, and has important reference significance for formulating intervention plans for depressed elderly people.
This study has several limitations. Firstly, due to incomplete pension and insurance data, we did not include the elderly’s pension insurance and economic status in this study. These variables may affect the relationship between walking ability, frailty, and depression in the elderly. Secondly, the subjects are from China, so the research results may be affected by cultural and regional factors, and are not applicable to the elderly in other countries. Future studies may take into account enlisting a larger variety of people from other nations and areas to get fresh insights into the connection between depression, frailty, and old walking abilities. Thirdly, the mechanisms underlying the impact of walking ability and frailty on depression are not yet clear, and further exploration is needed in future research on the mechanisms underlying the impact of walking ability and frailty on depression.
Acknowledgments
The authors thank all the participants in CHARLS team for their time and effort devoted to the project.
Author contributions
Conceptualization: Yin Hang, Caizhu Gao, Yaqun Zhang.
Data curation: Yin Hang, Caizhu Gao, Zhengri Quan, Yaqun Zhang.
Formal analysis: Caizhu Gao, Yaqun Zhang.
Investigation: Yin Hang, Caizhu Gao, Zhengri Quan, Yaqun Zhang.
Methodology: Yin Hang, Caizhu Gao, Zhengri Quan, Yaqun Zhang.
Software: Caizhu Gao, Zhengri Quan.
Writing – original draft: Yin Hang, Yaqun Zhang.
Writing – review & editing: Yin Hang, Yaqun Zhang.
Abbreviations:
- BMI
- body mass index
- CHARLS
- China Health and Retirement Longitudinal Study
- CI
- confidence interval
- OR
- odds ratio
- PA
- physical activity
The authors have no conflicts of interest to disclose.
This study was supported by the Liaoning Province Economic and Social Development Research Project (2024lslqnkt-043) and the Anshan Social Science Federation Key Project (as20232041).
The datasets generated during and/or analyzed during the current study are not publicly available, but are available from the corresponding author on reasonable request.
How to cite this article: Yin H, Gao C, Quan Z, Zhang Y. The relationship between frailty, walking ability, and depression in elderly Chinese people. Medicine 2023;102:45(e35876).
Contributor Information
Hang Yin, Email: yinhang9277@163.com.
Caizhu Gao, Email: gaocaizhu521@163.com.
Zhengri Quan, Email: quanzhengri2022@163.com.
References
- [1].Zhong B, Xu Y, Xie W, et al. Depressive symptoms in elderly Chinese primary care patients: prevalence and sociodemographic and clinical correlates. J Geriatr Psychiatry Neurol. 2019;32:312–8. [DOI] [PubMed] [Google Scholar]
- [2].Yu-Xing Y, Yuan-Wen Q, Jian-Kui G, et al. Effects of five elements music therapy of traditional Chinese medicine on the mental health of the elderly patients with depression. China J Tradit Chin Med Pharm. 2019;34:2787–90. [Google Scholar]
- [3].Chan S, Pan Y, Xu Y, et al. Life satisfaction of 511 elderly Chinese stroke survivors: moderating roles of social functioning and depression in a quality of life model. Clin Rehabil. 2020;35:269215520956908. [DOI] [PubMed] [Google Scholar]
- [4].Won S. The role of poverty on depression and self-rated health of older adults living alone: the mediating effect of social participation. Korea Acad Ind Coop Soc. 2020;21:520–6. [Google Scholar]
- [5].Hu Z, Wu Y, Yang H, et al. Effects of fertility behaviors on depression among the elderly: empirical evidence from China. Front Public Health. 2021;8:570832. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [6].Zhang H, Jiang Y, Rao W, et al. Prevalence of depression among empty-nest elderly in China: a meta-analysis of observational studies. Front Psychiatry. 2020;11:608. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [7].Luo Y, Li Y, Xie J, et al. Symptoms of depression are related to sedentary behavior and sleep duration in elderly individuals: a cross-sectional study of 49,317 older Chinese adults. J Affect Disord. 2022;308:407–12. [DOI] [PubMed] [Google Scholar]
- [8].Cui L, Ding D, Chen J, et al. Factors affecting the evolution of Chinese elderly depression: a cross-sectional study. BMC Geriatr. 2022;22:109. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [9].Miao J, Wu X, Sun X. Neighborhood, social cohesion, and the Elderly’s depression in Shanghai. Soc Sci Med. 2019;229:134–43. [DOI] [PubMed] [Google Scholar]
- [10].Zheng W, Huang X, Suo M, et al. Protocol for the FACE study: frailty and comorbidity in elderly patients – a multicenter, Chinese observational cohort study. J Geriatr Cardiol. 2023;20:83–90. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [11].Li Q, Zhang Q, Zhang S, et al. Relationship between frailty and cognitive decline in Chinese older patients with Alzheimer’s disease: the mediating role of social contact. Geriatr Nurs. 2022;43:175–81. [DOI] [PubMed] [Google Scholar]
- [12].Yiming P, Pan L, Yun L, et al. Metabolomics-based biomarkers for frailty in Chinese older adults. Innov Aging. 2021;5(S1):534. [Google Scholar]
- [13].Chuan Z, Qian Y, ChunYan W, et al. Association of depression with cognitive frailty: a systematic review and meta-analysis. J Affect Disord. 2023;320:133–9. [DOI] [PubMed] [Google Scholar]
- [14].Kim YH, Cho CM. The mediating effect of frailty in the relationship between depression and falls among older people living alone in Korea. Iran J Public Health. 2022;51:596–605. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [15].Gao W, Dai P, Wang Y, et al. Associations of walking impairment with visual impairment, depression, and cognitive function in US older adults: NHANES 2013–2014. BMC Geriatr. 2022;22:1–10. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [16].Yu DJ, Yu AP, Leung CK, et al. Comparison of moderate and vigorous walking exercise on reducing depression in middle-aged and older adults: a pilot randomized controlled trial. Eur J Sport Sci. 2022;23:1018–27. [DOI] [PubMed] [Google Scholar]
- [17].Omar HR, Guglin M. Depression significantly reduces the 6-minute walking distance in systolic heart failure: insights from the ESCAPE trial. Eur J Intern Med. 2017;41:e30–2. [DOI] [PubMed] [Google Scholar]
- [18].Zhang Y, Xin J. The relationship between walking ability, self-rated health and depressive symptoms in middle-aged and elderly people after controlling demographic, health status and lifestyle variables. Medicine (Baltimore). 2023;102:e34403. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [19].Zhao Y, John S, Chen X, et al. China Health and Retirement Longitudinal Study Wave 4 User’s Guide, National School of Development, Peking University; 2020. [Google Scholar]
- [20].van der Ploeg HP, Tudor-Locke C, Marshall AL, et al. Reliability and validity of the international physical activity questionnaire for assessing walking. Res Q Exerc Sport. 2010;81:97–101. [DOI] [PubMed] [Google Scholar]
- [21].Macfarlane D, Chan A, Cerin E. Examining the validity and reliability of the Chinese version of the International Physical Activity Questionnaire, long form (IPAQ-LC). Public Health Nutr. 2011;14:443–50. [DOI] [PubMed] [Google Scholar]
- [22].Dong L, Qiao X, Tian X, et al. Cross-cultural adaptation and validation of the FRAIL scale in Chinese community-dwelling older adults. J Am Med Dir Assoc. 2017;19:12–7. [DOI] [PubMed] [Google Scholar]
- [23].Mei H, Cunxian J. Evaluation of the reliability and validity of the CES-D depression scale for different populations in rural areas. China Public Health J. 2012;28:1265–7. [Google Scholar]
- [24].Sang N, Li BH, Zhang MY, et al. Bidirectional causal relationship between depression and frailty: a univariate and multivariate Mendelian randomisation study. Age Ageing. 2023;52:afad113. [DOI] [PubMed] [Google Scholar]
- [25].Ji L, Qiao X, Jin Y, et al. Age differences in the relationship between frailty and depression among community-dwelling older adults. Geriatr Nurs. 2020;41:485–9. [DOI] [PubMed] [Google Scholar]
- [26].Alexandra M, Mihaela A, Ramona S, et al. Relationship between frailty and depression in a population from North-Eastern Romania. Int J Environ Res Public Health. 2022;19:5731. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [27].Cristina B, Celia P, Fernández JG, et al. The relationship between depression and frailty syndrome: a systematic review. Aging Ment Health. 2015;15:762–72. [DOI] [PubMed] [Google Scholar]
- [28].Chung BPH, Lau TFO. Proactive outcome monitoring and standardisation of physiotherapy stroke rehabilitation—a retrospective functional outcomes analysis of Accelerated Stroke Ambulation Programme. Hong Kong Physiother J. 2023;43:117–27. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [29].Van Liew C, Gudesblatt M, Covey TJ, et al. The moderating roles of self-efficacy and depression in dual-task walking in multiple sclerosis: a test of self-awareness theory. J Int Neuropsychol Soc. 2022;29:274–82. [DOI] [PubMed] [Google Scholar]
- [30].Turhan K, Tuba O, Zuhal A, et al. Associations between smoking and walking, fatigue, depression, and health-related quality of life in persons with multiple sclerosis. Acta Neurol Belg. 2020;121:1199–206. [DOI] [PubMed] [Google Scholar]
- [31].Reinholdsson M, Grimby-Ekman A, Persson HC. Association between pre-stroke physical activity and mobility and walking ability in the early subacute phase: a registry-based study. J Rehabil Med. 2021;53:m1123. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [32].Mobily K, Rubenstein L, Lemke J, et al. Walking and depression in a cohort of older adults: the iowa 65+ rural health study. J Aging Phys Act. 1996;4:119–35. [Google Scholar]
- [33].Jang Y, Kim G, Chiriboga DA. Gender differences in depressive symptoms among older Korean American immigrants. Soc Work Public Health. 2011;26:96–109. [DOI] [PubMed] [Google Scholar]
- [34].Bayes IM, Daniel F, Luis JMA, et al. Healthy aging and late-life depression in Europe: does migration matter? Front Med. 2022;9:866524. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [35].Lili J, Jinrong W, Baoqi Z, et al. Expressive suppression and rumination mediate the relationship between frailty and depression among older medical inpatients. Geriatr Nurs. 2021;43:293–8. [DOI] [PubMed] [Google Scholar]
- [36].Maria M, Sergey Y, Alex Z. Psychological aging, depression, and well-being. Aging (Milano). 2020;12:765–77. [Google Scholar]
- [37].Shimada H, Lee S, Doi T, et al. Prevalence of psychological frailty in Japan: NCGG-SGS as a Japanese National Cohort Study. J Clin Med. 2019;8:1554. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [38].Freitag S, Schmidt S, Kwan SJ. Psychosocial correlates of frailty in older adults. Geriatrics. 2016;1:26. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [39].Bayes IM, Daniel F, Luis A, et al. Healthy aging and late-life depression in Europe: does migration matter? Front Med. 2022;9:758120. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [40].Verhaak P, Dekker J, Waal DM, et al. Depression, disability and somatic diseases among elderly. J Affect Disord. 2014;167:187–91. [DOI] [PubMed] [Google Scholar]
- [41].Ke C, Qiao Y, Liu S, et al. Longitudinal research on the bidirectional association between depression and arthritis. Soc Psychiatry Psychiatr Epidemiol. 2020;56:1241–7. [DOI] [PubMed] [Google Scholar]
- [42].Borges MK, Aprahamian I, Romanini CV, et al. Depression as a determinant of frailty in late life. Aging Ment Health. 2020;25:2279–85. [DOI] [PubMed] [Google Scholar]
- [43].McDowell C, Dishman R, Hallgren M, et al. Associations of physical activity and depression: results from the Irish Longitudinal Study on Ageing. Exp Gerontol. 2018;112:68–75. [DOI] [PubMed] [Google Scholar]
- [44].Luciana R, Pedro P, Nelson W, et al. Symptoms of anxiety and depression and their relationship with barriers to physical activity in patients with intermittent claudication. Clinics. 2021;76:e1802. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [45].Anderson BM, Qasim M, Correa G, et al. Depression is associated with frailty and lower quality of life in haemodialysis recipients, but not with mortality or hospitalization. Clin Kidney J. 2023;16:342–54. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [46].Jinseon Y, Young JY. Cognitive frailty increases the risk of long-term care dependency in community-dwelling older adults: a nationwide cohort study in South Korea. Geriatr Gerontol Int. 2023;23:117–23. [DOI] [PubMed] [Google Scholar]
- [47].An T, Man HKH, Chen Y, et al. Effects of non-pharmacological interventions on psychological outcomes among older people with frailty: a systematic review and meta-analysis. Int J Nurs Stud. 2023;140:104437–104437. [DOI] [PubMed] [Google Scholar]
- [48].Katarzyna L, Catherine R, Izabella U. Anxiety and depressive symptoms, frailty and quality of life in atrial fibrillation. Int J Environ Res Public Health. 2023;20:1066–1066. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [49].McKay MA, Mensinger JL, Whitehouse CR. The relationship of fear of falling and quality of life: the mediating effects of frailty and depression. J Community Health Nurs. 2022;39:251–61. [DOI] [PubMed] [Google Scholar]
- [50].Yaru J, Ruby Y, Huaxin S, et al. Effects of social support on frailty trajectory classes among community-dwelling older adults: the mediating role of depressive symptoms and physical activity. Geriatr Nurs. 2022;45:39–46. [DOI] [PubMed] [Google Scholar]