Informal care and cognitive frailty among Chinese older adults: the mediating role of social participation

doi:10.21203/rs.3.rs-4992831/v1

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Research Article

Informal care and cognitive frailty among Chinese older adults: the mediating role of social participation

https://doi.org/10.21203/rs.3.rs-4992831/v1

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Background and Objectives: With the intensification of ageing, cognitive frailty has become a major public health issue. The underlying mechanisms of the association between informal care and cognitive frailty were poorly understood. This study aimed to examine the mediating effect of social participation in the relationship between informal care and cognitive frailty among Chinese older adults.

Research Design and Methods: This research included 2,066 participants aged 60 and above from the China Longitudinal Study of Health and Retirement (CHARLS). We conducted the logistic regression model and Karlson-Holm-Breen(KHB) analyses to test the mediating role of social participation in the relationship between informal care and cognitive frailty.

Results: After adjusting the confounders, three dimensions ofinformal care were negatively associated with cognitive frailty (financial support: b = -0.110, P = 0.025; emotional support: b = -0.145, P = 0.037; life care:b = -0.304, P = 0.007). Social participation mediated the association between financial support and cognitive frailty (P = 0.008), as well as life care and cognitive frailty (P = 0.022). However, the mediating effect of social participation on the association between emotional support and cognitive frailty was insignificant (P = 0.660).

Discussion and Implications: Cognitive frailty was associated with informal care among Chinese older adults. Social participation mediated the association between financial support and cognitive frailty, as well as life care and cognitive frailty. More attention should be devoted to promoting social participation among Chinese older adults with cognitive frailty, especially those who receive life care and financial support.

Intermediary analysis

community

cognitive frailty

old adults

China's aging process can no longer be underestimated. By 2020, the population aged 60 years and above has accounted for 18.7%(1). In recent years, cognitive frailty has attracted widespread concern due to its increasing negative influence on older adults. Cognitive frailty is a new definition first proposed by the International Academy on Nutrition and Aging (I.A.N.A) and the International Association of Gerontology (I.A.G.G) in 2013(2). That is, in the absence of neurodegenerative diseases (Alzheimer’s disease or other types of dementia), cognitive frailty has the simultaneous presence of both physical frailty and cognitive impairment. Compared to single cognitive impairment or physical frailty, increasing studies have proved that cognitive frailty can powerfully predict all-cause mortality, disability, depression and other adverse health outcomes among older adults (3–7). Cognitive frailty not only brings care pressure and disease financial stress to the family, but also places a heavy burden on society and makes it difficult to achieve the allocation of health resources (8). However, cognitive frailty is reversible, and interventions such as emotional support and social participation have significantly improved cognitive frailty(7). Thus, exploring risk factors and interventions to prevent cognitive frailty among Chinese older adults is essential.

Informal care, which involves unpaid attention primarily centered around family and community, is extended to elderly individuals by spouses, offspring, other blood relatives, neighbors, and friends (9). Generally, informal care includes financial support, emotional support and life care(10, 11). Nowadays, with the increase in population, changes in population structure, and decrease in public expenditure, informal care has become the mainstream way of home care and a hot topic of discussion today(12, 13). More and more countries are emphasizing the “family-community” model of long-term care, with informal care as the main form of practice. Positive reforms in informal care have been realized, and the status of informal care is constantly being raised(14). Some studies have shown that informal care, as the primary source of social support for old adults, can promote health behaviors(10). In addition, previous studies have looked at each of the three factors of informal care to demonstrate the protective effect of the factor on cognitive frailty (15)(16). However, studies have yet to comprehensively explored the relationship between informal care and cognitive frailty among Chinese older adults.

Social participation, a potential modifiable protective factor for cognitive frailty, has captured extensive attention due to its low cost and high feasibility among older adults(16–18). Based on social exchange theory(19), older people who receive informal care use their free time to improve quality of life, for example by using free time to participate in various group activities. Previous studies suggested that positive emotional support, adequate financial support from adult children and life care encouraged older people to engage in the community actively (20, 21). One study conducted in Chinese communities found that older adults with more social participation were less likely to have cognitive frailty (22). Hence, based on the above theoretical and literature analysis, we hypothesize that social participation is a possible mediator between informal care and cognitive frailty among Chinese older adults.

This study aimed to explore the mediating effect between informal care and cognitive frailty among Chinese older adults. Our first aim is to examine the association between informal care and cognitive frailty. Then the second aim is to explore the mediating effect of the social participation between informal care and cognitive frailty. Our study will provide scientific evidence for improving cognitive frailty in older adults.

Date source

The data used in this study came from the 4th wave of the China Health and Retirement Longitudinal Study (CHARLS) in 2018. CHARLS is a large-scale national survey investigating health status and medical and health services utilization for Chinese adults aged 45 years and above. It was launched in 2011 and was followed up every two years. The CHARLS 2018 collected the information of 19,816 respondents. We excluded respondents aged under 60 (n = 9,203) and had missed data or abnormal values on key variables and covariates (n = 8,574). Finally, 2,066 respondents were included in our study.

Measures

Informal care

Informal care includes three dimensions: financial support, emotional support and life care. Financial support was measured by the amount of money the adult children gave(23). Emotional support was measured by how often older adults connected with others (11). Life care was measured by whether older adults were cared for(10). Detailed questions and assignment rules are in the supplementary material.

Cognitive Frailty

To measure the cognitive frailty(24), we adopted the frailty index and Mini Mental State Examination (MMSE)(25, 26) .Respondents who tested positive on both instruments were classified as exhibiting cognitive frailty and assigned a code of “1”, while those who did not meet this criterion were coded as “0”. The frailty index was composed of 5 dimensions and 32 items. In this study, we assigned a value to each item, culminating in a comprehensive frailty score. We divided the final total score by 32 to determine the individual frailty score. Individuals were categorized based on their scores as follows: those ranging from 0 to less than 0.25 were considered non-frail, while individuals with scores from 0.25 up to 1 were classified as frail(27). Detailed questions and assignment rules are in the supplementary material.

The MMSE was applied to evaluate an individual’s cognitive function. The MMSE score ranges from 0 to 30, with a high score indicating better cognitive function. The cut-off values for cognitive impairment on the MMSE vary based on educational attainment: illiterate (≤ 17), primary school (≤ 20), junior school (≤ 22), and university or higher education (≤ 24)(28).

Social participation

Social participation was assessed by the following question: “Have you participated in one of the following social activities in the past month?” in the questionnaire, with a total of 12 options, such as “went to a sport, social, or another kind of club”, “done voluntary or charity work” and so on. Detailed questions and assignment rules are in the supplementary material. The scores ranged from 0 to 11, with higher scores indicating higher levels of social participation(29, 30).

Other Covariates

Sociodemographic characteristics included gender (male/female), age (60–70, 70–80, ≥ 80), education (illiteracy/primary school/middle school/high school and above), marital status (single/married), residence (rural/urban). Medical insurance was divided into five categories (urban employee medical insurance/urban and rural resident medical insurance/urban resident medical insurance/new rural cooperative medical insurance/ others)(31). Living habit is defined by two variables: smoking status (yes /no) and drinking status (yes/no).

Statistical Analysis

All statistical analyses were performed using STATA 17.0. A p-value less than 0.05 was considered statistically significant. Firstly, descriptive statistics were used to describe the characteristics of participants. Second, the Student’s t-test and the Chi-square test were used to evaluate the association among the main variables, since the independent variables were non-normally distributed, we used Spearman's analysis to look at their relationship with cognitive frailty. Third, logistic regression analysis was use to explore the association between informal care and cognitive frailty, while the mediating role of social participation in this relationship was estimated by the Karlson-Holm-Breen (KHB) method(32).

Characteristics of Participants

Table 1 shows the participants’ characteristics. The 60–70 age group accounted for the largest proportion (63.41%), and 50.92% were male. The prevalence of cognitive frailty was 22.94%. The mean scores for social participation between respondents with and without cognitive frailty were significantly different (P<0.001). More information about the participants’ characteristics is shown in Table 1.

Table 1

Univariate analysis of older adults in CHARLS 2018 (N = 2066)
Characteristics, N(%)	Total N (%, n = 2066)	Non-cognitive frailty N (%, n = 1592)	Cognitive frailty N (%, n = 474)	χ²/t	P- value
Age				24.301	< 0.001
60–70	1310 (63.41)	1052 (66.08)	258 (54.43)
70–80	628 (30.40)	456 (28.64)	172 (36.29)
≥ 85	128 (6.20)	84 (5.28)	44 (9.28)
Gender				12.378	< 0.001
Male	1014 (49.08)	815 (51.19)	199 (41.98)
Female	1052 (50.92)	777 (48.81)	275 (58.02)
Marital status				9.186	0.002
Having spouse	1560 (75.51)	1227 (77.07)	333 (70.25)
No spouse	506 (24.49)	365 (22.93)	141 (29.75)
Education				28.834	< 0.001
Illiterate	429 (20.76)	301 (18.91)	128 (27.00)
Elementary school	991 (47.97)	755 (47.72)	236 (49.79)
Middle school	391 (18.93)	326 (20.48)	70 (13.71)
High school or above	255 (12.34)	210 (13.19)	45 (9.49)
Residence				11.829	0.001
Urban	661 (31.99)	540 (33.92)	121 (25.53)
Rural	1405 (68.01)	1052 (66.08)	353 (74.47)
Smoking status				12.080	0.001
Yes	513 (24.83)	424 (26.63)	89 (18.78)
No	1553 (75.17)	1168 (73.37)	385 (81.22)
Drinking status				29.822	< 0.001
Yes	618 (29.91)	524 (32.91)	94 (19.83)
No	1448 (70.09)	1068 (67.09)	380 (80.17)
Medical insurance				15.793	0.003
Urban employee medical insurance	389 (18.83)	328 (20.6)	61 (12.87)
Urban and rural resident medical insurance	269 (13.02)	198 (12.44)	71 (14.98)
Urban resident medical insurance	116 (5.61)	87 (5.46)	29 (6.12)
New rural cooperative medical insurance	1239 (59.97)	936 (58.79)	303 (63.92)
Other	53 (2.57)	43 (2.7)	10 (2.11)
Social participation, Mean (SD)	0.86 (± 1.07)	0.92 (± 1.12)	0.62 (± 0.83)	34.201	< 0.001
Financial support from adult children (FinSupFAC)				7.941	0.047
600 ≥ FinSupFAC ≥ 0	525 (25.41)	398 (25.00)	127 (26.79)
2600 ≥ FinSupFAC > 600	517 (25.02)	387 (24.31)	130 (27.43)
6500 ≥ FinSupFAC > 2600	510 (24.69)	388 (24.37)	122 (25.74)
47600 ≥ FinSupFAC > 6500	514 (24.88)	419 (26.32)	95 (20.4)
Life care				1.747	0.186
Yes	874 (42.30)	661 (41.52)	213 (44.94)
No	1192 (57.70)	931 (58.48)	261 (55.06)
Emotional support				0.292	0.292
Almost every day	1637 (79.24)	1251 (78.58)	386 (81.43)
Almost every week	189 (9.15)	148 (9.30)	41 (8.65)
Almost every month	117 (5.66)	89 (5.59)	28 (5.91)
Seldom	123 (5.95)	104 (6.53)	19 (4.01)
^aFinSupFAC: Financial support from adult children

Correlation between Key Variables

Spearman’s correlation analysis revealed that the financial support from adult children (β = -0.110, P = 0.025), emotional support (β = -0.145, P = 0.037), life care (β = -0.304, P = 0.007) were all negatively related to cognitive frailty. Financial support from adult children (β = 0.011, P < 0.001) and life care (β = 0.146, P = 0.002) were positively correlated with social participation. Emotional support was not related to social participation (β = -0.007, P = 0.794). Table 2 presents the correlation between social participation, subgroups of other factors and cognitive frailty. We found that social participation was negatively related to cognitive frailty (β = -0.218, P < 0.001).

Table 2

Logistic regression analysis of informal care and cognitive frailty among older adults (N = 2066)
Characteristics	Cognitive frailty
Characteristics	OR	95% CI	P-value
Age
60–75	Ref.
75–85	0.448	0.209, 0.686	< 0.001
≥ 85	0.759	0.335, 1.184	< 0.001
Gender
Male	Ref.
Female	0.126	-0.135, 0.388	0.344
Marital status
Having spouse	Ref.
No spouse	0.137	-0.122, 0.396	0.299
Education
Illiterate	Ref.
Elementary school	-0.037	-0.314, 0.240	0.793
Middle school	-0575	-0983, -0.167	0.006
High school or above	-0.059	-0.507, 0.389	0.797
Residence
Urban	Ref.
Rural	0.231	-0.092, 0.554	0.162
Smoking status
Yes	Ref.
No	0.244	-0.049, 0.537	0.103
Drinking status
Yes	Ref.
No	0.498	0.226, 0.770	< 0.001
Medical insurance
Urban employee medical insurance	Ref.
Urban and rural resident medical insurance	0.423	0.037, 0.883	0.072
Urban resident medical insurance	0.531	0.006, 1.056	0.048
New rural cooperative medical insurance	0.331	-0.073, 0.735	0.108
Other	0.150	-0.618, 0.918	0.702
Financial support from adult children (FinSupFAC)
60 ≥ FinSupFAC > 0	Ref..
2600 ≥ FinSupFAC > 600	-0.043	-0.338, 0.251	0.774
6500 ≥ FinSupFAC > 2600	-0.040	-0.340, 0.259	0.792
47600 ≥ FinSupFAC > 6500	-0.326	-0.642, -0.010	0.043
Life care
Yes	Ref.
No	-0.438	-0.684, -0.192	< 0.001
Emotional support
Almost every day	Ref.
Almost every week	-0.081	-0.460, 298	0.675
Almost every month	-0.110	-0.572, 0.352	0.640
Seldom	-0.632	-1.152, -0.112	0.017
Social participation	-0.218	0.340, 0.096	< 0.001
^aFinSupFAC: Financial support from adult children

Mediating Effect Analyses

Table 3 shows mediation analysis results based on the KHB method. After adjusting for social participation, there was a significant negative correlation between three dimensions of informal care and cognitive frailty among Chinese older adults. (1) The direct effect c’ between adult children’s financial support and cognitive frailty was not significant (P = 0.062), and indirect effect was significant(P = 0.008); (2) The direct effect c’ between life care and cognitive frailty was significant (P = 0.022), and indirect effect (P = 0.015) was also significant; (3) The direct effect c’ between life care and cognitive frailty was significant (P = 0.034), and the indirect effect a*b (P = 0.660) was not significant.

Table 3

The direct and indirect effects of informal care on cognitive frailty through social participation
Cognitive frailty				95% CI
Cognitive frailty	β	SE	P-value	Lower	Upper
Financial support
Total effect	-0.110	0.049	0.025	-0.207	-0.136
Direct effect	-0.093	0.050	0.062	-0.190	0.005
Indirect effect	-0.018	0.007	0.008	-0.031	-0.005
Emotion support
Total effect	-0.145	0.069	0.037	-0.281	-0.009
Direct effect	-0.148	0.070	0.034	-0.284	-0.012
Indirect effect	0.003	0.006	0.660	-0.009	0.015
Life care
Total effect	-0.304	0.112	0.007	-0.524	-0.083
Direct effect	-0.273	0.112	0.015	-0.493	-0.052
Indirect effect	-0.031	0.013	0.022	-0.057	-0.005

This study revealed two main findings. Firstly, all dimensions of informal care were negatively related to cognitive frailty. Second, social participation mediated these two associations: (1) financial support from adult children and cognitive frailty; (2) life care and cognitive frailty. The mediating effect of social participation was no longer significant in the association between emotional support and cognitive frailty.

This study found that financial support from adult children of informal care was associated with cognitive frailty in older adults, but when the mediating factor of social participation was added, the relationship between financial support from adult children and cognitive frailty was no longer significant. Financial support from adult children can significantly reduce the possibility of cognitive frailty in older adults, which is consistent with the findings of previous studies (8, 33). However, as a means of material incentives, financial support does not have a direct impact on cognition and physical frailty in older adults in the same way that emotional support and life care do. Meanwhile, our study finds that social participation mediated the relationship between financial support and cognitive frailty. Previous studies have confirmed that when older adults obtain financial support, they will have more abilities to get the corresponding social support and related medical resources(33), thereby improving their cognitive frailty(34). For older people over 60 years of age, social participation is the main way for them to feel social support(15, 35), and social participation has become the first target of transformation for older people after they have received financial support. In the process of participating in social activities, with the increase of physical activity and team collaboration, the physical frailty of older adults will be improved(36). Individual depression and social fear among older adults will also be reduced due to communication barriers being broken down(35). Then, their cognitive frailty may be improved through social participation(22).

Most studies have proven emotional support and companionship to impact older adults positively. Our study provides evidence consistent with Choi’s findings that a negative association exists between emotional support and cognitive frailty in older adults(16). Liu et al. also confirmed that when older adults met with their children or friends more often and received more frequent emotional support, their cognition and physical frailty would be improved(37, 38). Maintaining emotional support can give older adults a sense of belonging and emotional satisfaction(37, 39), stimulate brain activity and release neurochemicals such as oxytocin and dopamine(40, 41). Emotional support can reduce depression and social isolation and then increase their happiness and enthusiasm for life, and further improve their cognitive frailty state. Unlike previous studies(42), we found no significant correlation between emotional support and social participation in old adults, we explored the reason for this may be that older adults can already achieve the same effect as participating in social activities by only obtaining emotional support, and realize the improvement of cognitive frailty, a result that also side by side confirms the importance of emotional support for older adults.

According to Pecking order theory(31), older adults tend to give priority to informal care before receiving formal care. Therefore, receiving life care in informal care is the most common phenomenon among the older adults. Our study provides evidence that there is a negative association between life care and cognitive frailty in the older adults. Positive life care can regulate the health behaviors of the older adults, clump of overall control smoking, diet regulation, weight control, exercise maintenance, controlling the risk factors of cognitive frailty in the older adults from the source(10), so as to reduce the prevalence of cognitive frailty in the older adults. The study of Wang also showed that receiving the life care of children can reduce the depression of the older adults and improve physical frailty(23) Meanwhile, in the mediation analysis, social participation mediated part of the association between the relationship of the life care and cognitive frailty, and positive life care adequately regulated the health behaviors of the older adults, make them have the objective conditions and endogenous motivation to participate in social activities. So as to impel the frequency of their social participation, through team cooperation and active communication in the process of social participation, the improvement of cognitive frailty of the older adults can be achieved from both physical and psychological perspectives(39). Thus, older adults can also achieve improvements in cognitive frailty through social participation.

Our study revealed the relationship between the three dimensions of informal care and cognitive frailty, with social participation playing a mediating role in the relationships between financial support and cognitive frailty, and life care and cognitive frailty. This has implications for improving cognitive frailty in China's older population. Policy makers should continue to improve the informal care policy system and actively engage in multiple social activities. For those who are unable to participate in social activities, their life care should be strengthened in a timely manner, so as to realize the improvement of cognitive frailty.

There were several limitations in this study. First, it was a cross-sectional study, and causality could not be ascertained. Second, there may be other mechanisms between informal care and cognitive frailty, and future research should explore more factors to explain other pathways between informal care and cognitive frailty. Third, there is no strict division between family and community care in the informal care of this study. Thus, it cannot fully account for the effects of family and community care on cognitive frailty.

Our findings suggest that older adults who receive financial support, emotional support, and life care all have a significant improvement in their cognitive frailty state. The effect of financial support on cognitive frailty is fully sighted by the mediating role of social participation, and the effect of life care on cognitive frailty is realized by the partial mediating role of social participation. The government and relevant social departments should emphasize the role of informal care system and social participation, and take timely measures to improve the cognitive frailty status of Chinese older people.

KHB

Karlson-Holm-Breen

I.A.N.A

International Academy on Nutrition and Aging

I.A.G.G

the International Association of Gerontology

CHARLS

The China Health and Retirement Longitudinal Study

MMSE

Mini Mental State Examination

FinSupFAC

Financial support from adult children

Funding:

This work was supported by the National Science Foundation of China (grant numbers 72274109, 71774104, 71974117). The study sponsor has no role in study design, data analysis and interpretation of data, the writing of manuscript, or the decision to submit the paper for publication.

Author Contribution

Study concept and design: Chengchao Zhou. Acquisition of data: Tianyu Gao, Analysis and interpretation of data: Tianyu Gao, Dan Zhao. Drafting of the manuscript: Tianyu Gao. Critical revision of the manuscript for important intellectual content: Chengchao Zhou, Shujun Chai, Yang Liu, Yihong Sun, Yunxun Zhang, Jie Zhou and Zihan Lin. All authors read and approved the final manuscript.

Acknowledgments:

We thank the officials of health agencies, all participants and staffs at the study sites for their cooperation.

Data Availability

Availability of data and materials: The datasets generated and analyzed during the current study are available in the CHARLS and NHANES website, available in http://charls.pku.edu.cn/en and https://www.cdc.gov/nchs/nhanes/index.htm, respectively

Competing interests: The authors declare that they have no competing interests.

Ethics approval and consent to participate：Ethics approval and consent to participate Ethics approval for the study was granted by the Ethics Review Committee of Peking University (IRB00001052–11015), and all the participants provided signed informed consent at the time of participation. All the methods were performed in accordance with the relevant guidelines and regulations

Clinical trial number: not applicable.

Author details: ¹Centre for Health Management and Policy Research, School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan, 250012, China. ²School of Public Health, Cheeloo College of Medicine, Shandong University, 44 Wen-hua-xi Road, Jinan, Shandong, 250012, China. ³NHC Key Lab of Health Economics and Policy Research (Shandong University), Jinan, 250012, China. ⁴Institute of Health and Elderly Care, Shandong University, Jinan, 250012, China

Consent for publication: Not applicable

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Informal care and cognitive frailty among Chinese older adults: the mediating role of social participation

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Abstract

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Introduction

Methods

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Measures

Informal care

Cognitive Frailty

Social participation

Other Covariates

Statistical Analysis

Results

Characteristics of Participants

Correlation between Key Variables

Mediating Effect Analyses

Discussion

Conclusions

Abbreviations

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Data Availability

References

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