Abstract
Psychological frailty, including cognitive, mood, and motivational components, is an important predictor of overall well-being. Therefore, there is an increasing scientific interest in studying different determinants of psychological frailty. Unfortunately, the psychological components of frailty are not fully evaluated and currently, there is currently no consensus on the proper assessment or intervention. This study evaluated optimism and self-efficacy among frail older men without functional disability.
A case-control study. Seventy older men ≥60 years were divided into frail and non-frail groups. The self-efficacy scale (SES) and revised life orientation test (R-LOT) were applied for all participants, in addition to the comprehensive geriatric assessment, to determine other factors affecting physical frailty.
Those with physical frailty had lower self-efficacy and optimism scores. R-LOT and SES had moderate diagnostic accuracy in predicting frailty; the area under the curve for both tools were 0.75 and 0.71, respectively.
There is an association between poor general self-efficacy, low optimism, and frailty among older men. Thus, the importance of addressing the psychological determinants of frailty is on par with that of addressing the physical components. Integrating the SES and R-LOT scales into the comprehensive assessment of older men with physical frailty can improve the assessment of psychological resilience, ultimately promoting their well-being and quality of life.
Introduction
Frailty is a growing global health challenge that affects healthcare systems worldwide. The prevalence of frailty is exponentially rising due to graying of the population (1).
Frailty is a condition of reduced resilience due to dysregulated homeostasis that increases vulnerability to stressors and delays recovery (2), leading to many adverse outcomes, including dependence, falls, long-term institutionalization, hospitalization, and increased mortality (3).
Frailty is a multifaceted concept that extends beyond physical decline, encompassing a spectrum of deficits in cognitive, social, and psychological domains (4). Recently, psychological frailty was described as a multi-component concept that includes mood, cognitive, mental, and fatigue-associated problems (5).
Psychological resilience, optimism, and self-efficacy are interrelated constructs that play a crucial role in the ability to positively adapt to stressors (4, 5).
Optimism as a cognitive construct is defined as positive expectations regarding future outcomes (6). Older adults with higher levels of optimism have a longer lifespan (7), as they are more likely to embrace healthier lifestyles, such as participating in regular physical activity, eating a healthy diet, and smoking cessation (8).
Self-efficacy is defined as having the confidence of being able to accomplish a specific behavior to achieve specific performance expectations (9). Self-efficacy is flexible and responsive to change; thus, it can be effectively targeted in healthcare-related interventions. Augmenting self-efficacy promotes health behaviors such as physical exercise and maintaining a healthy diet (10). The impact of physical frailty on optimism and self-efficacy remains an area of limited research. These psychological factors should be examined for their potential role in patient-centered interventions. Therefore, this study quantified the effect of frailty on self-efficacy and optimism in older men.
Materials and Methods
A case-control study was conducted on 70 older men aged 60 years, and above recruited from the geriatric outpatient clinic at Mansoura University Hospital, Mansoura, Egypt, between August 2022 and March 2023. A sample size of 35 cases and 35 controls achieves a power of 80% according to Doba et al. (11). We used a purposive random sampling. The frailty status was rated according to the modifications of Fried criteria adopted by Avila-Funes et al. (12). The score ≥3 was considered frail. Those who scored 0 were non-frail (robust) individuals. Exclusion criteria: individuals categorized as pre-frail, patients with acute or chronic conditions that could interfere with the initial assessment or communication, patients with functional disabilities who need aid in one or more of the basic activities of daily living (ADL) (13), and patients with a diagnosis of dementia or depression.
Data Collection and Assessment Tools
The older men attending the clinic underwent comprehensive geriatric assessment and were assessed for eligibility through the following:
• Proper history taking.
• Mini nutritional assessment (MNA) (14) to evaluate the risk of malnutrition. The participants were rated malnourished if scored less than 17, at risk of malnutrition with scores between 17 and 23.5, and well-nourished with scores ≥24.
• The Arabic version of the mini-mental state examination (15, 16): excludes patients with dementia. The interpretation of results was performed according to the normal reference values adjusted for age and education (17).
• The Arabic version of the geriatric depression scale (GDS) (18, 19): those who scored five or more indicated potential depression, and accordingly, they were excluded from the study (20).
• ADL (21), and instrumental ADL (IADL) (22): those with ADL <6 were excluded based on the presence of physical disability.
The participants were assigned to either the frail group or the non-frail group using the physical frailty phenotype (PFP) (23), according to the modifications made by Avila-Funes et al. (12). The PFP includes five criteria: slowness, unintentional weight loss, weakness, low physical activity, and exhaustion.
Both groups underwent: optimism assessment using the Arabic version of the revised life orientation test (R-LOT) (24). The R-LOT is a self-report measure that assesses motivation and the participant’s expectations regarding future outcomes. This is a 10-item questionnaire consisting of direct-scored, reverse-scored, and filler items. Scores ranging from 0 to 13 indicated low optimism, 14 to 18 indicated moderate optimism, and 19 to 24 indicated high optimism.
Self-efficacy was assessed using the Arabic version (25) of the general efficacy scale (26). It is a self-report tool that assesses confidence in the ability to face challenges. It consists of 10 items rated according to a 4-point Likert scale ranging from 1 “not at all true” to 4 “exactly true”. The overall score ranges from 10 to 40. Higher scores (≥29) indicate high self-efficacy, whereas lower scores (<29) indicate low self-efficacy.
The study methodology was revised and approved by the Research Ethics Committee at the Faculty of Medicine, Ain Shams University (approval number: FMASU MS 490/2022, date: 9.8.2022). All study participants were interviewed during clinic visits. We respected confidentiality and obtained their informed written consent for participation.
Statistics
Collected data were encoded, tabulated, and statistically analysed using IBM Statistical Package for Social Sciences (SPSS) statistics software version 28.0 (IBM Corp., Chicago, USA, 2021. Quantitative data were described as mean ± standard deviation and compared using an independent t-test for two independent groups and an ANOVA test for three independent groups. Qualitative data were described as numbers and percentages and compared using the chi-square test or Fisher’s Exact test. The receiver operating characteristic curve was used to evaluate the performance of self-efficacy scale (SES) and R-LOT for diagnosing physical frailty. A p<0.050 was considered significant.
Results
Seventy older men were enrolled in this study; they were evenly divided between the frail and non-frail groups. The sociodemographic variables were matched between the two groups.
Compared with the robust group, the frail group reported an increased prevalence of sleep problems, social inactivity, and higher chronic pain levels. In addition, MNA and IADL scores were notably lower, malnutrition was more prevalent, GDS scores were significantly higher, and there was a significantly higher number of comorbid conditions. Moreover, body mass index (BMI) was significantly lower in the frail group (Table 1).
Self-efficacy, measured by SES, had a mean score of 25.3±5 among frail group and 28.1±4.6% in the robust group, whereas optimism, measured by R-LOT, had a mean score of 12.7±3.3 in the frail group compared with 16.6±4.4 in the robust group. Both SES and R-LOT scores were significantly lower in the frail group (Table 2). Both R-LOT and SES demonstrated moderate diagnostic accuracy in predicting frailty, with an area under the curve of 0.75 for R-LOT ≤17 and 0.71 for SES ≤30 (refer to Figure 1).
Self-efficacy was significantly lowest in patients with low optimism as measured by R-LOT, with no significant difference between moderate and high grades (Table 3).
There was a positive correlation between SES and R-LOT scores, with (r=0.611, p<0.0001). After adjusting for the following confounding factors (MNA score, presence of chronic pain, sleep problems, and the number of comorbidities), the correlation analysis between SES and R-LOT score was (r=0.518, p=0.003) in the frail group and (r=0.568, p<0.001) in the robust group (Table 4).
Discussion
In this study, health-related factors affecting frailty were evaluated, and the effect of frailty on optimism and self-efficacy was assessed. Both SES and R-LOT scores were significantly lower in the frail group. Moreover, there was a positive correlation between the R-LOT and SES scores. The SES score was significantly lower in patients with low optimism; however, there was no significant difference between moderate and high levels of optimism regarding SES scores. The impact of physical frailty on self-efficacy has attracted increasing attention in the past few years. In addition to its impact on emotional, behavioral, and cognitive performance, self-efficacy also affects the biological responses to stressors, playing an essential role in both mental and physical well-being (27). There was a direct effect of general self-efficacy on frailty in 327 hospitalized older patients aged ≥60 years with chronic medical conditions. However, loneliness played a mediating role in this relationship (27).
Hladek et al. (10), in their study, reported that high self-efficacy was negatively correlated with pre-frailty and frailty. The odds of frailty decreased by 91% after adjusting for confounding factors (age, comorbidities, and life events). Furthermore, low self-efficacy was an independent predictor of frailty in a linear regression model (11).
In their prospective cohort study, Hladek et al. (28) reported that low general self-efficacy predicted incident frailty during seven years of follow-up. The risk of incident frailty increased by 41% in older adults with low self-efficacy after adjustment for other confounding variables.
Optimism as a psychological construct was associated with the adoption of healthy behaviors. Studies have shown that optimistic adults tend to have enhanced health status and that optimism can benefit those with various chronic medical conditions, including cancer, diabetes, cardiovascular, and neurological diseases (29). In this study, 62.9% of frail men had low optimism levels, whereas only 31.4% of those in the robust group exhibited low levels of optimism. It is well established that optimistic people tend to adapt more effectively to the challenges of aging and life stressors by using coping strategies such as problem-solving, seeking support from others, and reevaluating situations to find more positive views (30).
Similar findings were reported by Kim and Won (31), who found that individuals with frailty exhibited lower levels of optimism than those without frailty. This association persisted after accounting for age, malnutrition, cognitive function, and physical activity. However, this association between frailty and optimism was partially attributed to depression.
Wang et al. (32) reported that a higher level of optimism decreased the odds of frailty. However, after adjusting for age, gender, social factors, self-rated health, smoking, dietary factors, and physical activity, optimism was no longer associated with frailty.
The SES score was significantly lowest in cases with low optimism. This association was anticipated, given the shared conceptual underpinnings of self-efficacy and optimism and their established role in predicting overall well-being (6).
The association between the two constructs was evaluated in relation to academic performance (33), psychological health (34), and inflammatory bowel disease activity (35). However, to date, no study has examined this relationship in frail men. 51.4% of our frail patients were underweight. Our result aligns with the observation made by Xu et al. (36) who found that those with low BMI were more at risk of frailty. Similarly, Wu et al. (37) showed that the incidence of sarcopenia increases with low BMI. According to the Fried criteria of PFP, unintentional weight loss and/or BMI <18 kg/m2 were addressed as a component of physical frailty (23).
There was an increased prevalence of higher chronic pain among patients. This agrees with other studies in which the prevalence of both frailty and chronic pain was related (38-40).
Sleep problems are another important determinant of frailty. Our study is consistent with Pourmotabbed et al. (41), who found that experiencing daytime sleepiness, breathing sleep problems, and prolonged sleep latency increased the risk of frailty. In our participants, the lack of social activities was more prevalent among the frail group. This aligns with previous research indicating that the risk of physical frailty was higher in those experiencing social isolation and a sense of loneliness, especially in older men (42, 43). We agree with Zhang et al. (44) that malnutrition and high risk of malnutrition were substantially more frequent among the frail group.
Frail were more dependent on IADL compared with the control group. Many researchers have concluded similar results (45, 46). Generally, frail older adults are more prone to develop or worsen disabilities in ADL and IADL.
Although older adults with depression (GDS ≥5) were excluded from this study, frail cases scored higher on GDS. Accumulating evidence suggests a reciprocal relationship between depressive symptoms and physical frailty in older adults. They are both common among older adults, and each of them can increase the likelihood of developing the others (47).
The number of comorbidities was higher among frail men. Diabetes mellitus was more prevalent in the frail group (57.1%). This is consistent with previous studies showing an association between multimorbidity and frailty. Indeed, most frail older adults have multiple chronic conditions, but not all multimorbid individuals are frail. Nevertheless, multimorbidity increases the risk of mortality in frail patients (48, 49).
Study Limitations
We recognize that our study has certain limitations. The relatively small sample size and the use of a case-control design limit our ability to establish definitive causal relationships. Moreover, the study participants were men and predominantly from the young-old age group; thus, further research is needed to validate these findings in women and older participants. Additionally, inclusion of patients with moderate pain could have biased the results because pain can negatively impact mood and other psychological factors. Future interventional psychological and behavioral studies are needed to determine the potential protective effect of promoting self-efficacy and optimism on frailty.
Conclusion
An association exists between poor general self-efficacy, low optimism, and the presence of frailty among older men. The SES and R-LOT scales were moderately accurate in predicting frailty. Therefore, these scales could be used as part of a comprehensive evaluation of frail older men. Healthcare providers, particularly geriatricians, should address the psychosocial determinants of frailty. Psychological interventions that enhance self-efficacy, optimism, and other aspects of psychological frailty are crucial. These interventions, in addition to managing other factors such as nutrition, physical activity, polypharmacy, depression, sleep problems, social isolation, and traditional medical interventions for physical frailty, could significantly benefit older adults by delaying the onset of frailty and mitigating its negative consequences.
