Psychological Resilience to the Challenges of Physical Aging in Older U.S. Veterans: Results from the 2019-2020 National Health and Resilience in Veterans Study

Abstract

Objectives:

To employ a novel analytic approach to quantify psychological resilience to physical health difficulties and identify factors associated with greater resilience in older U.S. veterans.

Methods:

Data from a nationally representative sample of older U.S. military veterans (n=3,001), who participated in the National Health and Resilience in Veterans Study were analyzed to develop the Psychological Resilience Against Physical Difficulties Index (PRAPDI). Multiple regression and relative importance analyses were conducted to identify factors associated with greater PRAPDI scores.

Results:

Secure attachment style [17.3% relative variance explained (RVE)], mindfulness [16.6% RVE], and purpose in life [15.0% RVE] emerged as the strongest correlates of PRAPDI scores.

Conclusions:

Intervention strategies aimed at fostering mindfulness, attachment security, and purpose in life may help promote psychological resilience to the challenges of physical aging in older veterans.

1. OBJECTIVE

As life expectancy increases globally, identifying factors that contribute to improved health and well-being in late-life is of growing importance, especially since healthy, disease-free lifespan has not increased as quickly as life expectancy (1). Physical health conditions are associated with increased risk for mental health difficulties, which can in turn negatively impact functioning and overall quality of life (2). To date, however, scarce research has examined factors that may help promote psychological resilience to aging-related physical health challenges. Characterization of modifiable factors that may help foster resilience to such challenges is critical to informing prevention and treatment efforts aimed at promoting mental health in the face of these difficulties.

U.S. military veterans represent an important segment of the older U.S. adult population and are an ideal population in which to examine resilience to physical health challenges. First, U.S. military veterans are on average twenty years older than the U.S. civilian population (median age of 64 vs. 44) (3). Second, veterans have higher rates of exposure to potentially traumatic events such as military combat, as well as increased risk for stress- and trauma-related disorders such as posttraumatic stress disorder (PTSD), mood and anxiety disorders (4). Third, veterans have elevated rates of physical health conditions and multimorbidities, which may further increase risk for psychiatric morbidities (4, 5). To date, however, no study of which we are aware has examined factors associated with resilience to physical health challenges in this population.

To address this gap, we analyzed data from a contemporary, nationally representative sample of U.S. veterans to evaluate the following two aims: 1] employ a novel analytic approach to quantify resilience to physical health difficulties in later life; and 2] identify sociodemographic, military, and psychosocial characteristics associated with greater resilience to physical health difficulties. Based on prior work (6–8), we hypothesized that protective psychosocial factors such as mindfulness, purpose in life, and secure attachment style would emerge as key correlates of resilience to physical health difficulties in older veterans.

2. METHODS

2.1. Sample

The National Health and Resilience in Veterans Study (NHRVS) is a nationally representative survey of 4,069 U.S. veterans that was conducted between 18 November 2019 and 8 March 2020. Details on recruitment can be found in the Supplemental Methods. Briefly, the NHRVS sample was recruited from a probability-based, online, non-volunteer access survey panel of a nationally representative sample of adults that covers approximately 98% of U.S. households. The current study focused on veterans age ≥ 60 years (n=3,001; 73.8%). Veterans completed a 50-minute, anonymous, web-based survey. All participants provided informed consent and the study was approved by the Human Subjects Committee of the VA Connecticut Healthcare System.

2.2. Sociodemographic, military, health and psychosocial variables

Several variables were examined as potential correlates of resilience to physical health difficulties, and were selected based on previous work by our group and others (6–8) (Table S1). Exploratory factor analyses were conducted to generate regression-weighted factor scores for sets of variables assessing common constructs (e.g., protective psychosocial characteristics, social connectedness, religiosity/spirituality. See Supplemental Methods for further details).

2.3. Physical health difficulties

A broad range of physical health difficulties were assessed, including 20 physical health conditions (e.g., chronic pain, cancer, kidney, cardiovascular, or pulmonary disease, autoimmune disorders), obesity, disability in activities of daily living (ADLs) and/or instrumental ADLs (IADLs), severity of somatic symptoms and insomnia, and physical health-related functioning (Table S1).

2.4. Psychological distress composite score

A composite measure of current psychological distress was computed by conducting an exploratory factor analysis of measures of current severity of transdiagnostic symptoms of major depressive, generalized anxiety, and posttraumatic stress disorders (Table S1).

2.5. Data analysis

Data analyses proceeded in three steps. First, we conducted a multiple regression analysis to generate a Psychological Resilience Against Physical Difficulties Index (PRAPDI), in which a composite measure of psychological distress was regressed on multiple measures of physical health, including 20 physical health conditions (e.g., chronic pain, cancer, kidney, cardiovascular, or pulmonary disease, autoimmune disorders), obesity, ADLs and/or IADLs, severity of somatic symptoms and insomnia, and physical health-related functioning (Table S2). Residual scores for each veteran were calculated and then inverted such that higher PRAPDI scores reflected lower psychological distress given higher levels of physical health difficulties (Figure S1). Second, we conducted bivariate correlation analyses to identify sociodemographic, military, and psychosocial variables associated with PRAPDI scores. Variables that were significantly associated with these scores at the p<0.05 level in bivariate analyses were then entered into a multiple regression analysis to identify independent correlates of these scores. If an aggregate factor score (e.g., social connectedness) emerged as significant in this analysis, we conducted post-hoc analyses to identify which component variable was associated with PRAPDI scores. Third, independent correlates of PRAPDI scores were entered into a relative importance analysis to identify variables that accounted for the majority of explained variance (R²) in these scores after accounting for intercorrelations among these variables.

3. RESULTS

On average, the sample was 73.2 (range=60–99) years old, predominately male, white/non-Hispanic, married/partnered, and had a household income ≥$60,000. About a third of participants completed a college degree and were combat veterans (Table S3).

Results of a regression model used to derive PRAPDI scores indicated that physical health variables collectively explained 34.7% of the variance in psychological distress scores (Table S2).

Bivariate analyses (Table 1) revealed that greater age, male sex, mindfulness, protective psychosocial characteristics, social connectedness, and higher positive expectations of aging scores were associated with higher PRAPDI scores, while greater number of traumas, military sexual trauma, adverse childhood experiences, and prior mental health treatment were negatively associated with these scores.

Table 1.

Sociodemographic, trauma history, and psychosocial variables with significant bivariate correlations to PRAPDI scores, and their relative associations when entered into a multiple regression prediction model in aging veterans.

	Bivariate correlation with PRAPDI	Multiple regression PRAPDI prediction model Adjusted R2 = 0.154
Demographic and Military Characteristics	r	β	t[df=10]	p
Age	0.09**	0.02	0.85	0.39
Male sex	0.07**	0.03	1.28	0.20
White, non-Hispanic race/ethnicity	−0.01	-	-	-
Married/living with partnered	0.02	-	-	-
College graduate or higher education	0.04	-	-	-
Household income $60K or greater	0.04	-	-	-
Retired	0.04	-	-	-
Combat veteran	−0.03	-	-	-
Years of military service	0.004	-	-	-
Physical Activity	r	β	t	p
Exercise level	−0.03	-	-	-
Trauma and Mental Health History	r	β	t	p
Adverse childhood experiences	−0.12**	−0.03	1.27	0.20
Cumulative trauma burden	−0.07**	0.00	0.17	0.86
Military sexual trauma	−0.09**	−0.02	1.15	0.25
Mental health treatment	−0.22**	−0.13	5.89	<0.001
Positive Psychosocial Factors	r	β	t	p
Mindfulness	0.23**	0.12	5.43	<0.001
Protective Psychosocial Characteristics Factor	0.28**	0.17	6.97	<0.001
Purpose in life	0.27**	-	-	-
Dispositional optimism	0.20**	-	-	-
Dispositional gratitude	0.13**	-	-	-
Curiosity/exploration	0.17**	-	-	-
Grit	0.22**	-	-	-
Coping self-efficacy	0.22**	-	-	-
Community integration	0.15**	-	-	-
Social Connectedness Factor	0.25**	0.12	4.97	<0.001
Structural social support	0.08**	-	-	-
Perceived social support	0.23**	-	-	-
Attachment style	0.23**	-	-	-
Positive Expectations of Aging	0.12**	0.02	0.83	0.41
Expectations regarding physical aging	0.02	-	-	-
Expectations regarding emotional aging	0.18**	-	-	-
Expectations regarding cognitive aging	0.06**	-	-	-
Religiosity/spirituality factor
Religious service attendance	0.03	-	-	-
Private spiritual activities	0.01	-	-	-
Intrinsic religiosity	0.03	-	-	-

Note: PRAPDI=Psychological Resilience Against Physical Difficulties Index.

Significant bivariate association with PRAPDI scores:

^**p<0.001.

Model F_[df=10,2060]=38.55, p<0.001.

When the significant bivariate correlates were entered into a multivariable regression model (Table 1), prior mental health treatment, greater mindfulness, protective psychosocial characteristics, and social connectedness emerged as independent correlates of greater PRAPDI scores. Post-hoc analyses revealed that greater purpose in life (β=0.12, t_[df=16]=4.39, p<0.001), grit (β=0.08, t_[df=16]=3.10, p=0.002), dispositional optimism (β=0.05, t_[df=16]=2.03, p=0.043), secure attachment style (β=0.09, t_[df=12]=3.53, p<0.001), and perceived social support (β=0.08, t_[df=12]=3.24, p=0.001) drove associations between protective psychosocial characteristics and social connectedness, and PRAPDI scores.

A relative importance analysis (Figure S2) identified three variables that explained nearly 50% of the variance in PRAPDI scores: secure attachment style (17.3% RVE), mindfulness (16.6% RVE), and purpose in life (15.0% RVE). Past mental health treatment, which was negatively associated with PRAPDI scores, accounted for 15.4% RVE, and perceived social support, dispositional optimism, and grit explained the remainder of the variance in these scores.

4. DISCUSSION

Using data from a nationally representative sample of older U.S. military veterans, we employed a novel analytic approach to operationalize psychological resilience to physical health difficulties, and identified characteristics associated with greater resilience in this population. Within the aging research community, there is increasing awareness of the so-called “aging paradox,” in which mental health improves later in life despite declining physical and cognitive function (9). This observation is “paradoxical,” as research in younger adults has revealed positive linear associations between physical health difficulties and severity of psychiatric symptoms, which would predict much greater severity of such symptoms as a consequence of increasing physical health problems associated with aging (9). In the current study, we employed a novel analytic approach that can be used to quantify this discrepancy and examine psychological resilience to physical health difficulties. This approach yields a resilience score (i.e., PRAPDI) that is derived from a regression model in which a composite measure of psychological distress is regressed on a broad range of physical health indicators.

We then evaluated sociodemographic, military, and psychosocial characteristics associated with higher PRAPDI scores (i.e., greater psychological resilience to physical aging). The strongest correlates of these scores were having a secure attachment style, greater mindfulness, and having a greater sense of purpose in life. Despite relatively small significant β weights estimated by the multivariable regression model (β=|0.12–0.17|), these associations were statistically significant (p<0.001), and a relative importance analysis indicated that these factors explained 17.3%, 16.6% and 15.0% of variance in PRAPDI scores, respectively. This finding suggests that prevention and treatment strategies designed to foster attachment security, mindfulness, and purpose in life (10, 11) may help enhance psychological resilience to physical health difficulties in older veterans. Of note, history of mental health treatment accounted for 15.4% of the explained variance in PRAPDI scores, which suggests that past mental health difficulties may be associated with greater chronicity of psychological distress and difficulty in adjusting to the challenges associated with physical aging. This finding further underscores the importance of continued assessment, monitoring, and treatment of underlying mental health problems in older veterans with and at increased risk for physical health difficulties.

Limitations of this study must be noted. First, the cross-sectional design, reliance on self-report assessments, and recruitment of a homogeneous (predominantly white/non-Hispanic males) older veteran sample limits conclusions about temporal associations and generalizability of the results. Second, our assessment of PTSD, MDD, and GAD symptoms did not specifically index these symptoms to physical health difficulties, so while physical health difficulties were strongly associated with psychological distress (R²=0.347), it is possible that PRAPDI scores may also reflect a more generalized resilience to stressful life events. Nevertheless, the majority of the sample endorsed an index trauma that can negatively affect physical health, including a motor vehicle or other serious accident (23.8%), life-threatening illness or injury (13.1%), combat or war-zone exposure (12.2%), and assaultive violence (8.4%). Thus, ratings of PTSD symptoms were largely driven by index traumas that may influence physical health. Third, the variance explained in PRAPDI scores was relatively modest (R²=0.154), so additional research that considers a broader range of potential factors associated with resilience to aging-related physical health challenges is needed. Fourth, the potential relationship between the construct of resilience assessed by the PRAPDI and other measures of resilience, particularly those developed for use in older adult populations (12, 13), was not evaluated. Further research is needed to examine whether the PRAPDI measures resilience specific to physical health challenges or a more general resilience to stressful life events.

Notwithstanding these limitations, this study describes a novel methodological approach to quantifying and identifying modifiable correlates of psychological resilience to physical health challenges. Further research is needed to identify biopsychosocial mechanisms underlying the observed associations; replicate results of the present study to evaluate the construct validity of the PRAPDI as a measure of psychological resilience, particularly in more diverse populations; and evaluate the efficacy of interventions targeting attachment security, mindfulness, and purpose in life in promoting psychological resilience to physical health challenges in veterans and other at-risk populations; or if these factors could be used to identify individuals who are more or less likely to be resilient when faced with physical health and other adversities associated with aging.

Highlights.

• We employed a novel statistical approach to assess psychological resilience to physical health challenges in older U.S. military veterans.

• Having a secure attachment style, and greater mindfulness and sense of purpose in life were most strongly associated with psychological resilience to physical health challenges.

• The identified correlates may help inform targets for prevention and intervention strategies aimed at promoting psychological resilience in the face of age-related physical challenges in older veterans.