Associations of frailty and psychosocial factors with autonomy in daily activities: a cross-sectional study in Italian community-dwelling older adults
Clinical Interventions in Aging
Associations of frailty and psychosocial factors with autonomy in daily activities: a cross-sectional study in Italian community-dwelling older adults
Anna Mulasso 2
Mattia roppolo 1 2
Fabrizia giannotta 0
emanuela rabaglietti 2
0 Department of Psychology, University of Uppsala , Uppsala, sweden
1 Department of Developmental Psychology, rijksuniversiteit of groningen , groningen, the n etherlands
2 Department of Psychology, University of Torino , Torino , Italy
Frailty has been recognized as a risk factor for geriatric adverse events. Little is known of the role of psychosocial factors associated with frailty in explaining negative outcomes of aging. This study was aimed at 1) evaluating the differences in psychosocial factors among robust, prefrail, and frail individuals and 2) investigating whether there was any interaction effect of frailty status with empirically identified clusters of psychosocial factors on autonomy in the activities of daily living (ADLs). Two-hundred and ten older adults (age 73±6 years, 66% women) were involved in this study. Frailty was assessed using an adapted version of the frailty phenotype. The psychosocial factors investigated were depressive symptoms using the 20-item Center for Epidemiologic Studies Depression Scale, social isolation using the Friendship Scale, and loneliness feeling using the eight-item UCLA Loneliness Scale. The autonomy in ADLs was measured with the Groningen Activity Restriction Scale. Thirty-one percent of participants were robust, 55% prefrail, and 14% frail. We performed an analysis of covariance which showed differences between robust, prefrail, and frail individuals for all the psychosocial variables: Center for Epidemiologic Studies Depression Scale, F(2, 205)=18.48, P0.001; Friendship Scale, F(2, 205)=4.59, P=0.011; UCLA Loneliness Scale, F(2, 205)=5.87, P=0.003, controlling for age and sex. Using the same covariates, the two-way analysis of covariance indicated an interaction effect of frailty with psychosocial factors in determining ADLs, F(4, 199)=3.53, P=0.008. This study demonstrates the close relationship between frailty and psychosocial factors, suggesting the need to take into account simultaneously physical and psychosocial components of human functioning.
In Western countries, the percentage of older adults is expected to increase dramatically
in the coming decades. According to official projections,1 the population aged 65 or older
is expected to rise from 17.4% in 2010 to 29.5% in 2060, with a consistent increase of
people aged older than 80 (from 4.6% to 12.0% in the period between 2010 and 2060).
Among the European Union Member States, Italy was one of the “oldest” countries in
2012, with an aged population of 20.6%. People aged 80 or older were 6.1% of the total
population.2 The growing number of older people will probably increase the demands
on health care services. Thus, there is the need to intensify knowledge about aging
trajectories in order to find the most effective ways to promote health for older adults.
One of the risk factors for and the precursor of adverse geriatric outcomes is frailty.
A frail person has a higher risk of loss of autonomy in daily life (ADL), health-related
problems, institutionalization, hospitalization, and death, with consequent negative
Clinical Interventions in Aging 2016:11 37–45
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influences on the quality of life.3–10 In terms of prevalence, about
half of older adults have to deal with frailty. In a systematic
review, Collard et al reported an average prevalence rate of
10.7% for frailty and 41.6% for prefrailty.11 However, this
data showed enormous variability according to the operational
definition adopted. Considering its great impact on people’s
lives and its high prevalence rate in the aged population, it is
worth expanding the concept of frailty.
Frailty has been broadly defined but without achieving
consensus. Specifically, two opposing frailty definitions have
been developed. The first one considered frailty as a
singledimensional construct based on physical functioning and on
the biological/physiological state.12–14 The main and the best
known conceptualization of physical frailty is the one proposed
by Fried et al, who defined frailty as a biological syndrome
deriving from cumulative declines in different physiological
systems and resulting in a loss of reserves and resistance to
external stressors.13 The operational definition that results is the
.rvdoepww ll.syeuon epnhtesntohtryepeeoorfmfroariletyo,fatchceofrodlilnogwtionwghfiivceh pahfryasiilcianldcivoimdupaolnpernetss-:
/w an shrinking, weakness, poor endurance and energy, slowness,
tthp rspe and low physical activity level. Physically frail older adults,
from roF compared to robust ones, have a poorer quality of life15 and a
de higher risk of disability, health care utilization, hospitalization,
lado admission to nursing home, and mortality.3,16,17 Nonetheless,
now this vision of frailty is limited since it does not include the
gdn psychosocial component of human functioning.
igA Psychological and social features, such as cognitive
isn decline, depression, and low frequency of social contacts, may
itnon be related to negative health outcomes.18,19 Specifically, the
lItrvnee gdreeparteesrsuivsee soyfmnopnto-mmeantotalol-ghyeaalnthd saenrxviiecteys,aorensaestsoofcidaitseadbiwliittyh,
aanbsdernecdeuocefdsowceialll-sbuepinpgo,r2t0,a21reanrdeliastoeldattioomn,uloltnipelleindeissse,aasnedotuhtecomes and all-cause mortality.22–24 The idea is that not only
physical frailty but also a decline in psychological and social
functioning can be seen as risk factors for age-related decline.
On this basis, the second definition depicted frailty as a
multidimensional construct based on physical, psychological, and
social components, suggesting that many factors may
contribute to frailty in a complex way.25–27 In line with the assumptions
of the bio-psycho-social model,28,29 physical, psychological,
and social components of frailty must be seen as integrated
concepts that could better explain human functioning.25,30,31
Consistent with this vision, Gobbens et al defined frailty as “a
dynamic state affecting an individual who experiences losses
in one or more domains of human functioning” with, as a
consequence, higher risk for adverse outcomes.25 Studies in
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support of this frailty vision are still limited and report
controversial findings. For example, Dent and Hoogendijk
investigated the impact of psychosocial resources on the
relationship between physical frailty, measured with Fried’s
criteria, and negative outcomes in a sample of patients
admitted to hospital.32 They showed that frail individuals
with low psychosocial factors had an increased likelihood of
incurring negative outcomes (mortality, discharge to higher
level care, long length of hospital stay, and re-hospitalization)
compared to frail people with good psychosocial functioning.
Hoogendijk et al conducted similar research on a sample of
community-dwelling older adults, but did not find
significant interactions between physical frailty and psychosocial
resources.33 In this case, the outcomes used were functional
decline and mortality. Gobbens et al, using the Tilburg Frailty
Indicator (TFI), found an effect of physical frailty on disability
1 and 2 years later but not of psychological and social frailty.34
However, in another study, they demonstrated that the older
adults’ quality of life was affected by both the
psychological and the social components of the TFI.35 Finally, Ament
et al did not find any additional effect of psychological and
social dimensions of frailty on disability, quality of life, and
hospital admission.36 However, those authors used a sample of
only physically frail individuals. Given the mixed results and
methods of assessment, more studies are needed to understand
the relationship between physical frailty, psychosocial factors,
and negative outcomes in older adults.
In this study, we refer to the multidimensional
conceptualization of frailty. However, while this
multidimensionality has been theorized, it has not been widely supported
by empirical evidence. Our idea is that a multidimensional
concept of frailty that takes into account both physical and
psychosocial aspects is more useful in understanding the
decline in autonomy in older adults. To test this idea, we
investigated the contribution of depression, social isolation,
and feeling lonely, associated with the frailty phenotype,13 in
the explanation of ADLs in a sample of Italian
communitydwelling older adults. The specific aims were 1) to evaluate
differences in psychosocial factors among robust, prefrail,
and frail individuals and 2) to investigate the interaction
effect of physical frailty status (robust, prefrail, and frail)
and empirically identified clusters of psychosocial factors
(good, moderate, and low) on the ADLs.
Materials and methods
The participants of the present study represent a subset of
the Italian Regional project “Act on Ageing”, a longitudinal
3-year study that aimed at analyzing the effects of physical
and cognitive interventions on the health of people older
than 65 years. Nine hundred individuals were assessed for
eligibility, of whom 298 did not meet the inclusion criteria
of the research, 232 did not wish to participate, and three
were already involved in other studies. A total of 367 older
adults participated in the Act on Ageing project. For this
paper, data collected at the baseline were used. Excluding
missing values from the analysis (n=157), 210 participants
were considered. The participants’ subset (n=210) was not
statistically different in terms of demographic characteristics
and cognitive, physical, and psychosocial functioning from
the whole sample of the Act on Ageing project.
Participants who met the following criteria were included:
1) older than 65; 2) able to walk 500 m without assistance;
3) a Mini-Mental State Examination37 (MMSE) score 25;
4) a sedentary lifestyle (absence of participation in
regular moderate or vigorous physical activity in the previous
5 years); and 5) no severe health problems (eg, uncontrolled
hypertension, recent upper or lower extremity fractures,
myocardial infarction within the past 1 year). All participants
in the study lived in the Piedmont Region and did not need
The study was approved by the Ethical Committee of
the University of Turin. All participants provided informed
consent in accordance with Italian law and the ethical code
of the American Psychological Association.38 They did not
receive any incentives or reward for participating.
In the baseline evaluation, a large amount of data was
collected. First, the participants completed a battery of
self-reported questionnaires concerning the demographic
characteristics, psychosocial adjustment, quality of life, and
health condition, in the presence of a trained psychologist
in order to clarify any doubts. Second, an expert in physical
education and adapted physical activity for older adults
administered physical tests. Finally, people with expertise in
the field of ergonomics took anthropometric measurements.
Data collection was always carried out in the same order and
individually for each participant.
Physical frailty measure
To identify physically frail older adults, an adapted version
of the frailty phenotype of Fried et al was used.13
1) Shrinking was defined as a body mass index 21 kg/m2.3
Height and weight were detected by a Tanita Body Composition
Analyzer BF-350 (precision level of 0.1 kg) and by an
anthropometer (precision level of 0.1 cm, International Standard
ISO/TR 7250-2),39 respectively. 2) Weakness was evaluated
by handgrip strength. Handgrip strength was measured using
a Smedley hand dynamometer (baseline 12-0286). Three
attempts of maximal isometric strength were executed,
with alternating limbs, and the average value of the three
measurements was computed using the best mean value
between right and left limb for the analysis. The same cutoff
scores of the Cardiovascular Health Study were applied in
this research.13 A previous study demonstrated a good level
of test–retest reliability of the Smedley hand dynamometer.40
3) Poor endurance and energy was assessed by two items
from the Center of Epidemiologic Studies Depression scale
(CES-D): a) “I felt that everything I did was an effort”,
b) “I could not get going”. The statement referred to the past
week. As proposed by Fried et al,13 those who answered
“a moderate amount of the time (3–4 days)” or “most of
the time” to at least one of the questions were positive for
endurance and energy component. 4) Slowness was evaluated
by the Timed Up and Go (TUG) test,41 using the reference
values of Bohannon to classify subjects as frail for slowness.42
The TUG test consisted in rising from a chair, walking 3 m,
turning around a cone, walking back, and sitting down.
The test was executed once, in addition to an untimed trial.
5) Low physical activity was established in the subjects who
were not engaged in leisure activities, such as hiking, chores
(moderately vigorous), gardening, dancing, and cycling, at
least once a week.3 Subjects with three or more criteria were
classified as frail, those with one or two as prefrail, and those
meeting none as robust.13
Depressive symptoms were determined with the 20-item
CES-D.43 The CES-D investigates the common symptoms
of depression, such as poor appetite, fatigue, and pessimism,
which had occurred within the past week. The CES-D ranges
from 0 (no depressive symptomatology) to 60 (severe
depressive symptoms). It has been demonstrated to be a valid and
reliable instrument to identify older people at risk of major
depression.44,45 Following the example of Graham et al,46 the
two items of CES-D used to define poor endurance according
to Fried’s criteria were removed. The total CES-D score is
referred to 18 items, which exhibited high internal
consistency in this sample (α=0.85).
Social isolation was evaluated using the Friendship Scale
(FS).47 FS is a six-item instrument investigating social
relationships. Example items include: “It has been easy to relate to
others”, “I felt isolated from other people”, and “I had
someone to share my feelings with”. The score ranges between
0 and 24. Higher scores indicate social connectedness, and
lower scores social isolation. Analysis of psychometric
properties has suggested that FS is a reliable and valid instrument
to be used with older adults.47 Cronbach’s α in our sample
Feeling lonely was investigated with the short version
of the UCLA Loneliness scale (ULS),48 composed of eight
items. This short form was derived from the Revised ULS
version.49 Sample items include: “I lack companionship” and
“I feel isolated from others”. The total score ranged from 8
to 32. Higher scores correspond to greater loneliness feeling.
ULS is a reliable and valid instrument, commonly used with
people from adolescents to older adults.50 In this study, the
ULS reliability was α=0.89.
Age, sex, living conditions, level of education, and past job
were self-reported information. Questions about the condition
of health were the following: 1) “Do you usually use some
edrreudg.sO?nYleys/mNeod”ic(ivnietasmcoinnssuamndedsuopnpalermegeunltasrwbaesriesnwoetrceotnaskiedn/w an into account.) 2) “Do you experience poor vision? Yes/No”.
tthp rspe 3) “Do you experience difficulties in hearing? Yes/No”.
The Groningen Activity Restriction Scale (GARS) is a
non-disease-specific questionnaire to measure the level
of autonomy in the basic and instrumental ADLs.51,52
It comprises 18 items with four categories of response.
Its score ranges from 18 (absence of disability) to 72 (severe
disability). The GARS is widely used with older adults.53,54
A study of Suurmeijer et al reported satisfactory results in
terms of validity and reliability of the scale.52 Cronbach’s α
of 0.95 was obtained in the present study.
We presented descriptive statistics for all the variables.
We examined the internal consistency of the scales
with Cronbach’s α. Values of α0.70 were considered
acceptable.55 We carried out t-test for unpaired samples and
χ2 test for identifying any differences between participants’
subset of this study and the whole sample of the Act on
First, to determine differences in psychosocial
adjustment (depression symptoms, social isolation, and loneliness
feeling) among robust, prefrail, and frail individuals, we
carried out one-way analysis of covariance (ANCOVA) using
participant’s age and sex as covariates and the Sidak post hoc
test. Second, to individuate groups of subjects with similar
psychosocial profiles (CES-D, FS, ULS), we used cluster
analysis. We carried out the hierarchical cluster procedure
with Ward’s method, applying squared Euclidian distance
followed by k-means clustering. Significant differences
across the variables’ means of the clusters were provided with
one-way analysis of variance (ANOVA). Finally, to evaluate
whether the physical frailty status (robust, prefrail, and frail)
and the empirically identified clusters of psychosocial factors
(good, moderate, and low) interact and to analyze their impact
on disability, we used the two-way ANCOVA with age and
sex as covariates. For each statistical significant effect, we
executed the Sidak post hoc test.
For all tests, we set the level of significance at 0.05. We
conducted the statistical analysis with the Statistical Package
for Social Sciences (SPSS), Version 20.0 (IBM Corporation,
Armonk, NY, USA).
Baseline participant characteristics
Of the 210 participants, 139 (66%) were women. The mean
age was 73.4 years (standard deviation =5.9, range: 65–89).
All the subjects lived autonomously and were retired. Most
of them (52%) were married. Forty-one percent had a level
of attainment corresponding to primary school, and 62%
performed manual work (eg, housewife, seamstress, worker,
farmer, mason). A large number of participants (63%)
referred to having limitations in vision or hearing, or both,
and 82% used at least one drug. The mean score of MMSE
of 28.3 (standard deviation =2.3) confirmed the high level
of cognitive functioning of the participants. According to
Fried’s criteria, 31% (n=65) of participants were categorized
as robust, 55% (n=116) as prefrail, and 14% (n=29) as frail.
The baseline characteristics of the sample are summarized
in Table 1.
Differences in psychosocial adjustment
according to frailty status
The one-way ANCOVA, controlling for age and sex, reported
significant differences among robust, prefrail, and frail
individuals for all the psychosocial variables – depression,
social isolation, and feelings of loneliness. The worsening of
frailty status corresponded to a significantly greater severity
of each of the psychosocial variables. In respect to
depression symptoms, post hoc tests revealed differences among
all the three levels of frailty (robust vs prefrail, P=0.001;
robust vs frail, P0.001; prefrail vs frail, P0.001). For the
social isolation, post hoc tests showed that robust individuals
had higher social connectedness compared to the frail ones
(P=0.011). No differences in terms of social isolation were
found between frail and prefrail, as well as between prefrail
and robust groups. With respect to feelings of loneliness,
post hoc tests revealed that robust individuals suffered less
from loneliness than prefrail (P=0.036) and frail individuals
(P=0.004). No differences were found between prefrail and
frail groups (P0.05) for feeling lonely (Table 2).
effect of physical frailty and psychosocial
adjustment on ADls
To identify groups of individuals with a similar level of
psychosocial adjustment, a cluster analysis was run on the total
number of participants based on their score in the CES-D, FS,
and ULS scales. Hierarchical cluster analysis using Ward’s
method emphasized three clusters. All the cluster centers
differed from each other significantly (P0.001). The first
cluster included 73 subjects (35%), and was characterized
by low depressive symptoms associated with a high score
of social connectedness and low loneliness feelings. The
second cluster had the highest sample size (n=100, 47%).
Individuals included in this cluster showed medium scores
for psychosocial variables compared to the other two clusters.
The third cluster was composed of 37 individuals (18%),
affected by depressive symptomatology, poor friendship
network, and a high level of loneliness. The three clusters
obtained were identified as “good”, “moderate”, and “low”
level psychosocial adjustment. The descriptions of the
clusters are reported in Table 3.
A two-way ANCOVA, controlling for age and sex, was
conducted to determine whether the physical frailty status
(robust, prefrail, and frail) and the clusters of psychosocial
factors (good, moderate, and low) interact and whether they
have an impact on ADLs. A major effect of physical frailty,
)=5.15, P=0.007, on ADLs was found. Post hoc tests
showed that ADLs in frail older adults were lower compared
to prefrail (P=0.009) and robust individuals (P=0.002). No
differences in ADL were found between prefrail and robust
groups (P0.05). Similarly, psychosocial factors had a main
effect on ADLs, F(
)=3.29, P=0.039. Post hoc tests
revealed that ADL was higher in older people having a
moderate (P=0.020) and good (P=0.021) level of psychosocial
adjustment compared to those with low psychosocial level.
There were no statistical differences between individuals with
moderate and good levels of psychosocial factors (P0.05)
in terms of ADL. Furthermore, results showed a significant
interaction of physical frailty and psychosocial clusters on
ADL , F(
)=3.53, P=0.008. Specifically, a simple main
effects analysis demonstrated that frail older adults with a
low level of psychosocial adjustment were different in terms
of ADL from frail individuals with moderate (P0.001) and
good (P=0.008) psychosocial scores. No differences were
found for psychosocial adjustment in prefrail (P0.05) and
robust subjects (P0.05). Furthermore, frail subjects with a
low level of psychosocial adjustment had lower ADL
compared to the prefrail (P0.001) and robust (P=0.002) within
the same psychosocial group. No differences were detected
for good (P0.05) and moderate (P0.05) psychosocial
adjustment among frailty status (Table 4).
This cross-sectional study aimed to explore the role of
psychosocial factors, in association with physical frailty, in the
explanation of ADL in a sample of community-dwelling older
adults in Italy. First, we investigated psychosocial
adjustment among people with different frailty status. Second, we
tested whether there was an interactive effect of psychosocial
factors and physical frailty on the ADL of older adults. In
respect of frailty prevalence, our data on frail and prefrail
individuals was higher than those obtained in other studies
that used Fried’s criteria.56–58 Closer to our findings were
those from the Survey of Health, Aging and Retirement in
Europe59 and from the San Antonio Longitudinal Study of
Aging.60 The slightly higher prevalence rate for the frail and
prefrail obtained in our study is probably due to the typology
of older adults involved in the project. In fact, one of the
inclusion criteria was a sedentary lifestyle in the previous
5 years. It is possible that the absence of a regular moderate
or vigorous physical activity is a risk factor for several
components of frailty.61,62 Our findings demonstrated that
physical frailty is closely tied to a significant worsening of
psychosocial factors. Specifically, we found that depressive
symptoms, social isolation, and feelings of loneliness are
progressively higher in robust, prefrail, and frail groups. Our
results are consistent with those obtained by Langlois et al,63
who showed reduced cognitive and psychological measures
in frail subjects compared to robust one; of Collard et al,64
who reported an association between physical frailty and
more severe depressive symptomatology in adults older
than 60; and of Strawbridge et al,65 who found that robust
older adults were more likely to go out for entertainment and
visit with family or friends than frail subjects.
We also showed a significant interaction effect of
psychosocial adjustment levels and frailty status on ADL, demonstrating
that the performance of ADL differs depending on the
combination of both frailty and psychosocial factors. Frail subjects
with low psychosocial adjustment showed a lower level of
ADL compared to frail individuals with higher psychosocial
level. Similar results were found by Dent and Hoogendijk, who
found interaction effects of frailty with psychosocial factors on
different outcomes in a sample of hospitalized older adults.32
Our findings suggest that considering psychological and
social factors – not only physical factors – may improve
the explanatory contribution of “frailty” when it comes to
the prediction of ADL of older adults. This may have two
important implications: first, when it comes to the definition
of frailty, our results suggest that a multidimensional
definition that also includes psychological and social factors may
be more informative and accurate in the identification of older
adults at risk of negative events than a definition limited to
physical factors. Second, when it comes to prevention, a
multidimensional definition would allow the
implementation of more focused and person-centered interventions for
the prevention of frailty. Special attention should be paid to
older adults who simultaneously present physical frailty and
Frailty status Psychosocial level
a low level of psychosocial adjustment, because they are at
emergenti” within the Regional call “Bando Regionale
higher risk of loss of ADL. For these individuals, intervention
a sostegno di progetti di ricerca industriale e/o sviluppo
strategies that simultaneously act on multiple factors may be
sperimentale di applicazioni integrate e innovative in
more effective than those based on a single domain.66
ambito Internet of Data” funded by Regione Piemonte and
There are several noteworthy limitations in this study.
the “Fondo Europeo di Sviluppo Regionale (POR-FESR)”.
First, research participants were representative of a small area
The funding bodies were not involved in the study design,
of Italy and were included according to rigorous criteria,
makdata collection, and analysis or in writing the report. Anna
ing it impossible to generalize the results to the entire Italian
Mulasso and Mattia Roppolo received a research fellowship
aged population. Second, the sample size was not very large,
from the Department of Psychology, University of Torino
with some subgroups (eg, frail subjects) composed of a very
(reference number 17/2015, protocol no 320), funded by
limited number of participants. Despite the small sample size,
“Regione Piemonte” and the “Fondo Europeo di Sviluppo
the statistical power (1-β err prob =0.95) was reached. The
Regionale (POR-FESR)” for the project “Sistema di allerta
high number of missing values was also a limitation of the
integrato delle fragilità emergenti”.
study. Furthermore, the cross-sectional design of the research
did not allow the trends of frailty and psychosocial variables to
be studied longitudinally, and deepen the causal relationship
The authors declare no potential conflicts of interest with
between physical frailty, psychosocial factors, and clinically
respect to the research, authorship, and/or publication of
relevant geriatric outcomes. A further limitation concerns the
absence of a wider set of geriatric clinical outcomes (eg,
hospitalization, institutionalization, falls, use of health services),
which did not allow the evaluation of the impact of
psychosocial factors and physical frailty in a more exhaustive and
complete way. Finally, the application of an adapted version
of the frailty phenotype makes the comparison with results
from other studies difficult, as argued by Theou et al.67
In conclusion, this study confirms the close relationship
between physical frailty and psychosocial factors,
demonstrating that the increase in physical frailty status is
associated with a poor psychosocial adjustment in older adults.
Moreover, it also suggests taking simultaneously into account
physical and psychosocial aspects of frailty in order to
better explain the adverse events of aging and to better identify
older adults at risk of negative geriatric outcomes such as
the loss of ADL.
For the publication of this article, a funding has been received
from the project “Sistema di allerta integrato delle fragilità
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Clinical Interventions in Aging is an international, peer-reviewed journal
focusing on evidence-based reports on the value or lack thereof of treatments
intended to prevent or delay the onset of maladaptive correlates of aging
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