Intrinsic capacity and resilience in hospitalized older adults: a gender-stratified analysis of the PRIFOR score

Abstract

Background

The Physical Resilience Instrument for Older Adults (PRIFOR) was developed to assess recovery potential in older adults facing acute stressors. However, its core domains such as positive thinking, coping, and hopeful mindset suggest strong psychosocial underpinnings. The aim of this study is to evaluate association of PRIFOR with intrinsic capacity (IC) and length of stay (LOS) amongst hospitalized older adults stratified by gender.

Methods

We conducted a cross-sectional study involving 307 hospitalized adults aged ≥65 years. Data on IC domains, EuroQol 5-Dimension index (EQ-5D), EuroQoL Visual Analogue Scale (EQ-VAS), Charlson Comorbidity Index (CCI), and length of stay (LOS) was collected. Gender-stratified quantile regression models were used to assess associations across PRIFOR percentiles.

Results

Mean age was 76.5 ± 6.9 years and 50.8% were female. Decline in mobility domain was prevalent in 64.8%, psychological domain in 9.4%, cognition domain in 58.3% and vitality in 25.6%. Median LOS was 4 days. Association of PRIFOR quantiles(Q) with IC, QoL, and CCI was influenced by gender and nonlinear. Across both genders, PRIFOR was significantly associated with psychological domain (Q25th-75th) and EQ-5D index (Q75th). For mobility domain, the significance was only observed in male (Q25th-75th). In female, association was significant with CCI (Q50th,75th) and EQ-VAS (Q25th).

Conclusion

PRIFOR appears to capture broader resilience constructs beyond the physical domain, with distinct gender-related patterns in hospitalised older patients. Longitudinal studies are needed to determine the predictive value of PRIFOR in recovery and functional outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-026-07217-z.

Introduction

As global populations age and life expectancy continues to rise, there is a growing disparity between lifespan and healthspan [1]. This widening gap results in prolongation of sickspan which places significant pressure on healthcare systems. This demographic shift has prompted a growing recognition that healthcare systems must evolve beyond a disease-centric approach to one that emphasizes recovery, adaptation, and psychosocial well-being in later life [2]. While physical frailty is a well-established predictor of adverse health outcomes in hospitalised older adults, the notion of resilience influencing recovery trajectories has become an emerging research topic. A systematic review by Whitson and colleagues reinforced this concept, proposing that greater understanding and measurement of physical resilience could help identify protective factors and inform targeted interventions in geriatric care [3]. The World Health Organization’s World Report on Ageing and Health [4] has emphasized resilience as a critical component of healthy aging, defining it as the capacity to adapt to adversity, maintain function, and recover from stressors. Resilience is multidimensional, encompassing physical, psychological, and social domains. It is a continuum and can be dynamic, evolving over time as a function of development and through an individual’s interactions with the environment and exposure to stressors [5–8]. Physical resilience has been defined as the ability to resist or recover from functional decline after a health stressor, showing an individual’s capacity to return to baseline function [3, 9, 10]. Social resilience on the other hand is defined as the ability to tolerate, adjust or cope with environmental and social threats [11].

The Physical Resilience Instrument for Older Adults (PRIFOR) was developed as a self-report measure to quantify resilience in the context of acute health stressors [12]. It is subcategorised into three domains i.e. ‘Positive thinking’, ‘Coping and Lifestyle Adjustment’ and ‘Belief and hopeful mindset’[12]. Lin et al.[13] showed that it has good concurrent validity with depression, cognition, activity of daily living (ADL) and frailty in surgical inpatients. In another study by Fan et al.[14], PRIFOR has good validity and internal reliability, with a Cronbach ratio of 0.94.

Intrinsic capacity (IC) is defined by the WHO as the composite of an individual’s physical and mental abilities covering five domains: cognition, mobility, vitality, psychological, and sensory function [15]. IC is a measure of physiological reserve and may precede the onset of frailty. A recent study showed that PRIFOR was associated with all IC domains except vitality [16]. Li et al. commented that IC could be used to determine physical resilience in older adults [17]. In addition, IC has significant associations with frailty and quality of life. Maintenance of IC can lead to maintained physical ability, resulting in a higher quality of life amongst older adults [18]. It is therefore important to study the correlation between IC, resilience and quality of life indices, since each of these components may influence one another, and in turn affect health outcomes [19, 20].

Besides frailty, and acute illness, Gender differences can also influence resilience expression and impact. Despite having a larger gap between lifespan and healthspan, women frequently report higher psychological resilience [21]. Studies consistently shows that prevalence of frailty is higher in women compared to men, yet they tend to live longer [22, 23]. This phenomenon is sometimes referred to as the “male–female health-survival paradox“[23]. Studies suggest women often have stronger social network, and have better emotional coping strategies, whereas men value physical ability and functional independence [21].

Studies on PRIFOR have mainly focused on validation, and PRIFOR scores have shown significant association with frailty, and intrinsic capacity except vitality [12, 13, 16]. PRIFOR was initially developed based on a conceptual framework of physical resilience; however, prior validation work also suggests empirical associations with psychological and social domains [12]. There has not been much study into gender related differences for PRIFOR, although we do know that gender differences can lead to distinct health behaviours and health outcomes. The aim of this study is to evaluate association of PRIFOR with IC amongst hospitalized older adults stratified by gender, and also to examine the relationship between PRIFOR and physical, cognitive and psychological domains. Secondary outcomes include its association with length of stay (LOS). The gender differences in these associations will enable us to better understand how PRIFOR scores can inform more person-centred approaches in acute care.

Methods

Participants and Data Collection Procedure

Hospitalized older adults aged ≥ 65 years admitted under Geriatric Medicine were recruited within 48 h of admission based on eligibility from September 2023 to January 2025. This was a cross-sectional observational study conducted among hospitalized older adults to evaluate the association between resilience (measured using PRIFOR) and IC. Participants were randomly selected from daily admission lists during the study period. Only patients who were medically stable, mobile (ambulant or able to transfer with minimal assistance), and able to provide informed consent were included. Patients who were bedbound, critically ill, or undergoing active cancer treatment were excluded. The measures were self-reported by participants in English.

Measures

Demographics and Covariates

Trained study team members collected data on demographics, chronic diseases, polypharmacy, perceived health (EQ-5D, EQ-VAS), physical function, nutritional status, comorbidity burden, frailty, sarcopenia, cognition and mood.

Polypharmacy was defined as the use of five or more long-term medications. The EuroQol 5-Dimension (EQ-5D) index score was derived using the EQ-5D [24], and the EuroQoL Visual Analogue Scale (EQ-VAS) was used to assess participants’ self-rated health [25]. For assessment of physical function, data were collected on instrumental and basic activities of daily living, as well as performance on the Short Physical Performance Battery (SPPB). Lawton’s Instrumental Activities of Daily Living (IADL) scale was used to assess instrumental functional status, while the Katz Activities of Daily Living (ADL) scale assessed basic functional status [26, 27]. Physical performance was evaluated using the SPPB, which comprises three domains — gait speed, balance, and five-times sit-to-stand — with a maximum total score of 12 (4 points per domain). Nutritional status was evaluated using the Mini-Nutritional Assessment short-form (MNA-SF) [28]. Comorbidity burden was assessed using the Charlson Comorbidity Index (CCI). Frailty was assessed using the FRAIL scale [29], and sarcopenia screening using the SARC-F scale [30]. Cognition was assessed using the abbreviated mental test score and Mini-Cog [31]. Five-item Geriatric Depression Scale (GDS) was used to screen for depression [32].

Muscle strength, body composition and sarcopenia assessment

Hand grip strength (HGS) was measured using Jamar hand dynamometer on the dominant hand with participant in a seated position and elbow flexed 90°. Low HGS was defined as < 28 kg for males and < 18 kg for females [33]. Appendicular skeletal muscle (ASM) was measured using the InBody S10 multi-frequency bioelectrical impedance analyser (BIA) [33]. Sarcopenia was diagnosed based on the 2019 Asian Working Group for Sarcopenia (AWGS) criteria of gender specific cut offs for Appendicular Skeletal Muscle Index (ASMI) and low HGS (< 28 kg for males and < 18 kg for females) [33].

Resilience

PRIFOR is an instrument for assessing physical resilience in older adults. PRIFOR consists of 16 items with a 5-point Likert response scale (1 = strongly disagree to 5 = strongly agree) with a score range between 16 and 80. A high PRIFOR score indicates high resilience [12]. PRIFOR assessment was performed upon admission. The PRIFOR score and measurement of resilience in an individual conceptually aligns with the WHO Intrinsic Capacity (IC) framework, by acting as a moderator of functional decline, representing the capacity to maintain high function despite declining physiological reserves.

Intrinsic capacity

Four IC domains were assessed. A decline in mobility was defined as difficulty with ambulation or climbing stairs, based on responses from the FRAIL scale, SARC-F, or the EQ-5D ambulation domain. Decline in psychological domain was defined as either having moderate to extreme anxiety or depression on EQ-5D domain or 5-item GDS score of ≥ 2 [32]. Decline in cognitive domain was defined by AMT ≤ 7 or mini-cog cut-off of < 3 [34, 35]. Decline in vitality domain was defined by either having loss of appetite, malnourished or sarcopenic [36].

Statistical analysis

IBM SPSS Version 29.0 was used for statistical analysis. Categorical variables were presented as frequencies with percentages while continuous variables were presented as mean ± standard deviation in Table 1. χ2 or Fischer’s exact test were used for significance testing of categorical variables. For continuous variables, normality assumption was tested using Shapiro Wilk test. The Kruskal-Wallis test was used when continuous variables were not normally distributed. Significance testing for normally distributed variables with equal variances was carried out using one-way ANOVA. To further explore the relationship between PRIFOR scores, IC, CCI and key clinical outcomes, gender-stratified quantile regression models were employed to account for the non-linear distribution of PRIFOR. These models assessed associations with intrinsic capacity domains, EQ-VAS, EQ-5D index, CCI, and LOS at the 25th, 50th, and 75th percentiles of the PRIFOR distribution. Adjusted models were controlled for age, and comorbidities for IC. For EQ-VAS, EQ-5D, CCI and LOS, adjusted models were controlled for frailty and age. Results are reported as regression coefficients (β) with 95% confidence intervals (CI) and corresponding p-values, with statistical significance set at p < 0.05. All variables included in the descriptive and regression tables represent the full set of covariates examined in the univariate analyses. Variables that did not demonstrate statistical significance were retained and reported to ensure transparency and completeness of reporting.

Table 1.

Participant Characteristics

Characteristics	Total n = 307	Male 151 (49.2)	Female 156 (50.8)	P value
Age	76.5 ± 6.9	75.6 ± 6.8	77.3 ± 6.9	0.034
Body Mass Index (BMI)	23.6 ± 5.0	23.7 ± 4.6	23.6 ± 5.5	0.750
Ethnicity
Chinese	232 (75.6)	110 (72.8)	122 (77.9)	0.163
Malay	48 (15.6)	23 (15.2)	25 (16.0)
Indians	24 (7.8)	15 (9.9)	9 (5.8)
Others	3 (1.0)	3 (2.0)	0 (0)
Education (years)	7.2 ± 4.5	7.9 ± 4.0	6.5 ± 4.8	0.006
Employed	38 (12.3)	28 (18.6)	10 (6.4)	0.002
Main Caregiver
Self	149 (48.5)	76 (50.3)	73 (46.8)	0.012
Spouse	78 (25.4)	48 (31.8)	30 (19.2)
Child	55 (17.9)	18 (11.9)	37 (23.7)
Domestic Help	22 (7.2)	7 (4.6)	15 (9.6)
Institutional care	3 (1.0)	2 (1.4)	1 (0.6)
Chronic Medical Condition
Hypertension	216 (70.4)	102 (67.5)	114 (73.1)	0.318
Hyperlipidemia	217 (70.7)	110 (72.8)	107 (68.6)	0.453
Diabetes Mellitus	127 (41.4)	66 (43.7)	61 (39.1)	0.420
Ischemic Heart Disease	66 (21.5)	38 (25.2)	28(17.9)	0.129
Chronic Kidney Disease	24 (7.8)	14 (9.3)	10 (6.4)	0.236
Stroke	23 (7.5)	18 (11.9)	5 (3.2)	0.004
Osteoporosis	21 (6.8)	4 (2.6)	17 (10.9)	0.006
Charlson Comorbidity Index	5.0 (4.0–6.0)	5.0 (4.0–6.0)	5.0 (4.0–6.0)	0.142
Polypharmacy	50 (16.3)	27 (17.9)	23 (14.7)	0.537
≥ 1 ADL impairment	24 (7.8)	12 (7.9)	12 (7.7)	0.628
≥ 1 IADL impairment	115 (37.5)	57 (37.7)	58 (37.2)	1.000
Abbreviated Mental Test	8.9 ± 2.0	9.0 ± 1.9	8.6 ± 2.1	0.156
Low Handgrip Strength	252 (82.1)	128 (84.8)	124 (79.5)	0.238
SARC-F (≥ 4)	101 (32.9)	48 (31.8)	53 (31.0)	0.716
Low muscle mass	82 (26.9)	42 (28.0)	40 (25.8)	0.700
Sarcopenia	75 (24.6)	41 (27.3)	34 (21.9)	0.290
Loss of appetite	82 (26.7)	43 (28.5)	39 (25.0	0.521
SPPB (median (IQR))	4.0 (4.0–8.0)	4.0 (4.0–9.0)	4.0 (4.0–8.0)	0.161
Nutrition
At risk	102 (33.2)	45 (29.8)	57 (36.5)	0.132
Malnourished	6 (2.0)	5 (3.3)	1 (0.6)
FRAIL scale				0.370
Robust	113 (36.8)	50 (33.1)	63 (40.4)
Pre-frail	147 (47.9)	78 (51.7)	69 (44.2)
Frail	47 (15.3)	23 (15.2)	24 (15.4)
Depression	29 (9.4)	17 (11.3)	12 (7.7)	0.332
LOS (median (IQR)	4.0 (2.0–6.0)	3.0 (2.0–6.0)	4.0 (2.0–6.0)	0.677
EQ-5D VAS	64.0 ± 15.2	64.2 ± 14.7	63.7 ± 15.8	0.775
EQ-5D Index	0.96 ± 0.08	0.95 ± 0.9	0.96 ± 0.7	0.566
PRIFOR (median (IQR))
Total Score	52.0 (48.0–60.0)	52.0 (48.0–59.0)	52.0 (48.0–60.0)	0.426
Domain
Positive thinking	13.0 (12.0–16.0)	13.0 (16.0–12.0)	13.0 (12.0–16.0)	0.545
Cope adjustment	20.0 (18.0–23.0)	19.0 (18.0–23.0)	20.0 (18.0–22.8.0.8)	0.375
Belief hopeful	18.0 (18.0–22.0)	18.0 (18.0–22.0)	18.0 (18.0–23.0)	0.591
Intrinsic capacity domains
Mobility	199 (64.8)	102 (67.5)	97 (62.2)	0.193
Psychological	29 (9.4)	17 (11.3)	12 (7.7)	0.332
Cognition	179 (58.3)	88 (58.3)	91 (58.3)	1.000
Vitality	78 (25.6)	43 (28.7)	35 (22.6)	0.239

Bold: significant value, ADL Activity of Daily Living, IADL Instrumental Activity of Daily Living, SPPB Short Physical Performance Battery Test, LOS Length of Stay, PRIFOR Physical Resilience Instrument for Older Adults; n(%) unless stated otherwise

Results

The average age of 307 study participants was 76.5 ± 6.9 years and 50.8% were female patients (Table 1). The ethnic distribution mirrors Singapore’s ethnic composition with 75.6% Chinese, 15.6% Malay and 7.8% Indian. Almost half of the older patients did not require a caregiver prior to admission, and slightly more than one third required assistance in IADL. Female patients were significantly older, 77.3 years vs. 75.6 years. Males had higher education levels (7.9 vs. 6.5 years) and more likely to be employed (18.6% vs. 6.4%). There were significant differences in the main caregivers between genders where males were more likely to be cared for by spouse (31.8% vs. 19.2%), whereas females by own children (23.7% vs. 11.9%) or helpers (9.6% vs. 4.6%). Prevalence of stroke was significantly higher in males (11.9% vs. 3.2%) whereas osteoporosis in females (10.9% vs. 2.6%).

The quantile regression analysis examined associations across PRIFOR quartiles and the likelihood of having no impairment across the four IC domains, stratified by gender. Distinct patterns emerged across PRIFOR quartiles (Fig. 1 and Supplementary Table 1). Among male patients, a significant dose-response relationship was observed between increasing PRIFOR quartiles and preserved mobility, as indicated by rising adjusted β coefficients of 3.714 (95% CI: 1.735–5.693; p < 0.01) at 25th percentile to 6.684 (95% CI: 2.719–10.609; p = 0.007) at the 75th percentiles. In contrast, this association was not seen in females. In the psychological domain, both male and female exhibited significant positive association between higher PRIFOR quartiles and absence of depression. Amongst male, the adjusted β coefficient increased from 3.943(95% CI: 1.070–6.816; p = 0.007) at 25th percentile to 7.139 (95% CI: 1.412–12.867; p = 0.015) at 75th percentile. Female patients demonstrated even stronger associations, particularly in the highest quartile, with an adjusted β coefficient of 11.857 (95% CI: 5.927–17.787; p = < 0.001) at 75th percentile. There was however no significant dose-response relationship between increasing PRIFOR quartiles and cognition or nutrition domains for both genders.

Fig. 1.

Gender-Stratified Quantile Regression of PRIFOR Scores Against Intrinsic Capacity Domains (A-D) and Outcomes (E-F)

In the analysis of health-related quality of life, distinct gender-specific patterns were also evident. Among male participants, higher PRIFOR scores were positively associated with EQ-5D index values at the 75th percentile (β = 30.270; 95% CI: 4.744–55.796; p = 0.020). No significant associations were observed for EQ-VAS across PRIFOR quartiles in males. In contrast, among female patients, PRIFOR was significantly associated with EQ-VAS at the 25th percentile (β = 0.079; 95% CI: 0.023–0.135; p = 0.006). Additionally, the EQ-5D index was significantly associated with higher PRIFOR scores at the 75th percentile (β = 34.674; 95% CI: 8.770–60.578; p = 0.009).

No consistent or statistically significant associations were found between PRIFOR and LOS in either gender, though a trend toward shorter LOS was noted in females at 75th quantile (β = − 0.460; 95% CI: − 0.955 to 0.035; p = 0.068). PRIFOR was associated with lower CCI scores among females at higher quantiles (Q75: β = −1.363; 95% CI: −2.631 to −0.096; p = 0.035).

Discussion

PRIFOR scores demonstrate a non-linear distribution and its association with IC, QoL and CCI appear to be influenced by gender. Higher PRIFOR scores were associated with psychological well-being and EQ-5D index in both genders. In addition, for males, higher PRIFOR scores was also associated with better mobility and in females with CCI at higher quantiles. There was no significant association with cognition or nutrition, likely due to the confounding effects of acute illness during hospitalization. PRIFOR did not directly correlate with short-term healthcare utilization such as length of stay possibility due to the heterogenous nature of inpatient older adults who were admitted for various medical conditions.

PRIFOR was originally developed as a physical resilience tool to assess how older adults recover from acute stressors but its key domains are fundamentally psychosocial, suggesting substantial overlap with psychological and social resilience. There is no baseline physical function embedded in the PRIFOR tool. A strong and consistent association was observed between depression and PRIFOR scores in both genders across all the quantiles further supporting the notion that PRIFOR, unlike its name suggest may be a measure of psychosocial resilience. Among females, the association was even more pronounced, particularly at the upper quantile. These findings support existing literature highlighting the role of mental health—especially depression—in shaping adaptive capacity and social functioning in older adults [37]. Our study findings reinforce the importance of screening for depressive symptoms among hospitalised older adults [38], as psychological well-being appears to be closely intertwined with resilience and may influence recovery trajectories.

There was a significant and consistent association between mobility and resilience among male participants across all quantiles, particularly in the highest quantile, a pattern not seen in females. This suggests that among men, higher physical functioning maybe closely associated with stronger social coping capacity and engagement [39] Such gender disparity may reflect differences in social roles, coping mechanisms, or expectations around physical independence [40]. Men who are physically active and mobile may have a higher perceived resilience and social participation, which aligns with traditional gender norms around autonomy and functional ability. Conversely, women may draw resilience more from emotional, relational, or caregiving roles, which are less directly influenced by physical mobility [41]. Moreover, the reliance on self-reported mobility measures may introduce recall bias or reflect gendered perceptions of functional limitation. Older women, in particular, may normalize mobility challenges as part of aging, potentially attenuating the observed association with resilience. Studies highlight that although women are more likely to be classified as frail, they generally outlive their male counterparts suggesting psychosocial resilience may play a bigger role in this group. These findings indicate that mobility is fundamental to intrinsic capacity, but its impact on social resilience can vary by gender. Interventions must address both physical and psychosocial aspects, and consider gender-specific pathways to improve outcomes for older adults.

There were significant differences in EQ-VAS and EQ-5D index between genders amongst our study participants. For females with lower PRIFOR scores (Q25), a better perceived health was associated with a small but meaningful increase in their resilience score. This suggests that perceived health status may play a more influential role in shaping resilience among women with lower social reserves [42]. The impact of health status, as measured by the EQ-5D index, on resilience appears to be contingent on an individual’s level of social coping capacity. In quantile regression analysis, a one-unit increase in the EQ-5D index—representing a shift from the poorest to the best possible health state—is rarely observed in clinical populations. Therefore, the regression coefficient should be interpreted proportionally. For instance, a 0.1 increase in the EQ-5D index corresponds to an approximate 3.5-point increase in PRIFOR scores at the 75th percentile. This suggests that even modest improvements in health-related quality of life can meaningfully enhance resilience among individuals with higher baseline coping capacity. However, this association was not evident among those with low or moderate resilience, implying that the benefits of good health on resilience may only manifest once a certain threshold of adaptive capacity is reached [43].

Among female participants, higher social resilience—as measured by PRIFOR at the 50th and 75th percentiles—was significantly associated with lower CCI scores. This relationship may be bidirectional: female with fewer comorbidities may have a higher social resilience or women with greater social support, adaptability, and coping capacity may be more proactive in engaging in preventive health behaviours, seeking timely care and managing chronic illness well [44]. In contrast, this association was not observed in men, suggesting potential gender differences in how social resilience interacts with medical comorbidities. These findings highlight the importance of considering both psychosocial and clinical dimensions, particularly among older women, when analysing age-related health seeking patterns.

There were no association of vitality, cognition or LOS with PRIFOR scores amongst our study participants. Cognition and vitality were assessed within 72 h of admission, a period when acute illness, fatigue, delirium, inflammation, and treatment effects [45] may transiently affect these measures and limit their reflection of pre-illness baseline status, unlike self-reported pre-admission mobility. Similarly, short-term reductions in appetite or intake during hospitalization may be insufficient to influence psychosocial resilience. The absence of an association with LOS likely reflects its multifactorial determinants, including clinical complexity, psychosocial support [46], discharge processes, and system-level factors beyond individual resilience.

A key strength of this study is the use of the PRIFOR scale as a novel measure of resilience among hospitalized older adults, offering valuable insights into psychosocial domains that are often underexplored in hospitalised patients. However, several limitations merit consideration. First, PRIFOR is primarily composed of coping, adaptability, and social domain items, which captures subjective experience. Hence, administering the scale during hospitalization may introduce response bias. Acute stressors such as illness, hospitalisation, pain, medications and sleep disruption could alter perceptions of social support or coping ability. In addition, there is currently no standardized guidance on the optimal timing of its administration in the context of acute illness, unlike elective admissions. Second, the lack of significant associations between PRIFOR and cognition or nutrition may be influenced by timing and setting of assessments—acute illness commonly impairs appetite and transiently affects cognitive function especially in states of delirium or subsyndromal delirium, which may not reflect baseline status. Therefore, the lack of association does not necessarily imply that vitality is unimportant but suggests that it may not be a stable or sensitive indicator of social resilience during periods of acute illness. Additionally, potential recall bias could arise, especially among those with subclinical cognitive impairment or delirium, though it is notable that half of the participants had normal cognitive function. Mobility data, derived from self-reported questionnaires rather than performance-based measures, may also be subject to recall bias. The cross-sectional design limits causal inference, and the single-site study population may affect generalizability. We also acknowledge that intrinsic capacity consists of five domains, and our study managed to capture four out of five domains, with the exception of sensory function. Our sample was representative of Singapore’s multi-ethnic older population, generalizability to other cultural or healthcare contexts may be limited.

Future studies should consider longitudinal assessments, standardized timing of administration, measurement of post-acute recovery, and objective measures to validate PRIFOR’s predictive utility across clinical settings. Given its multidimensional nature and sensitivity to context, PRIFOR may be better suited for longitudinal evaluation post-acute recovery to fully capture its prognostic significance but may offer value in predicting broader recovery potential and quality of life.

Conclusion

This study demonstrates that higher resilience, as measured by PRIFOR, is significantly associated with better psychological well-being, with corresponding improvements in health-related quality of life as measured by the EQ-5D, in both genders. Gender-specific associations were observed with stronger associations between PRIFOR and mobility in males and CCI in females with higher resilience. As a self-reported measure, PRIFOR may be influenced by subjective perceptions and recall bias, and would benefit from validation against clinical outcomes. Nonetheless, PRIFOR shows promise as a brief, scalable tool for characterizing resilience profiles relevant to recovery and functional health in older adults. Future studies with longitudinal assessments, objective functional measures, and hard clinical outcomes are needed to establish its predictive validity and inform resilience-focused interventions in ageing populations.

Abbreviations

ADL

Activity of daily living

ASM

Appendicular skeletal muscle

ASMI

Appendicular Skeletal Muscle Index

AWGS

Asian Working Group for Sarcopenia

BIA

bioelectrical impedance analyser

CCI

Charlson Comorbidity Index

EQ-5D

EuroQol 5-Dimension index

EQ-VAS

EuroQoL Visual Analogue Scale

GDS

Geriatric Depression Scale

HGS

Hand grip strength

IADL

Instrumental Activities of Daily Living

IC

Instrinsic Capacity

LOS

Length of stay

MNA-SF

Mini-Nutritional Assessment short-form

PRIFOR

Physical Resilience Instrument for Older Adults

QoL

Quality of life

SPPB

Short Physical Performance Battery

Authors’ contributions

R.M, L.F wrote the initial draft of the manuscript. R.M, S.M.T was involved in investigation, data curation. R.M, L.F, J.T revised and edited the manuscript. All authors have read and agreed to the published version of the manuscript. All authors approved the final version of the article.

Declaration of Generative AI and AI-assisted technologies in the writing process

Generative AI tool – ChatGPT was used sparingly for grammar editing. The authors declare that generative AI tools were not used for any of the intellectual content, or scientific conclusion of the paper.

Funding

No funding was received to assist with the preparation of this manuscript.

Data availability

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Declarations

Ethics approval and consent to participate

This study was conducted in accordance with the principles of the Declaration of Helsinki and ethical approval was received by the National Healthcare Group Domain Specific Review Board [DSRB Ref: 2022/00499]. Written informed consent was obtained from all participants upon enrolment into this study. This study did not involve any healthcare interventions on human participants. Data were collected through interviews and physical assessments, with ethical approval obtained for the study.

Consent for publication

Not Applicable.

Competing interests

The authors declare no competing interests.