The Role of Predictive Anxiety, Depression, Cognitive Function, and Confidence in Balance for Participation, Level of Disability, and Duration of Physical Activity in Community-Dwelling Elderly Individuals
Abstract
Background and Objective: Aging can be described as a gradual decline in physical and mental abilities, accompanied by an increased susceptibility to illnesses and disabilities. This global phenomenon is escalating rapidly. Accurate prediction of future consequences based on identified factors is crucial for clinicians and researchers, particularly in progressive states such as aging. Thus, this study aims to investigate some of the most prevalent psycho-cognitive factors that may influence elderly individuals’ participation levels, disability status, and duration of physical activity.
Methods and Materials: In this correlational study, 150 subjects (87 males and 63 females) were selected through a simple non-probability sampling method from community-dwelling older adults in Tehran. Social participation, level of disability, and physical activity duration were evaluated using the CCIQ, the MHAQ, and a qualitative questionnaire, respectively. Anxiety and depression were assessed using the Hospital Anxiety and Depression Scale (HADS) and the Geriatric Depression Scale-15 (GDS-15), respectively. Cognitive function and balance were examined with the Montreal Cognitive Assessment (MoCA) and the Fullerton Advanced Balance (FAB) scale, respectively.
Results: The multiple regression models showed that FAB alone accounted for 13.5%−61.9% of the variance in all three outcomes. MoCA, GDS-15 and educational level were the second most significant predictorsof participation disability and physical activity time respectively.
Conclusion: These results suggest that treatments that target balance, cognitive, and depression states and improve manual function may be particularly important for improving participation, disability state, and physical activity time in community-dwelling older adults.
1. Introduction
Aging can be described as a chronic phase of human life characterized by a gradual decrease in physical and mental abilities, an elevated vulnerability to illnesses and disabilities (i.e., deviation from daily function) and a specific threshold of 81.2 years, beyond which older adults may experience a decline in their daily living functionality in a clinical context [1]. The global population is experiencing a rapid increase in age, and it is estimated that by 2030, there will be 1.4 billion people aged 60 years or older. This number is projected to reach 2.1 billion by 2050 [2].
Human metabolism research shows that older people have a lower basal metabolism rate (BMR) than younger people. In other words, elderly people consume the least calories needed from their daily diet to maintain the function of body organs [3]. In contrast, youth and children experience greater functional mobility, which leads to increased energy expenditure during activities [4]. Total energy expenditure decreases substantially in advanced age resulting from parallel changes in resting metabolic rate and activity energy expenditure. Therefore, daily energy expenditure can vary according to numerous factors, such as age, sex, physical activity, body mass, and diseases [5].
To preserve the appreciated metabolism, sense of well-being, and quality of life among older adults, one can accomplish this by sustaining both the frequency and duration of physical activity, as indicated by various studies [6], physical activity is crucial for promoting healthy aging and can impede or delay numerous age-related health complications.
Participation is an essential factor contributing to a fruitful aging process, enabling senior individuals to maintain their residence and become integrated within their community. Unfortunately, older adults facing functional limitations that impede mobility within their living environment and those experiencing compromised physical functionality are less inclined to participate in work, leisure, or social pursuits. On the other hand, excessive engagement in sedentary behaviors exhibits a notable correlation with impaired physical abilities, irrespective of the time allocated to moderate or vigorous physical activities [7]. Therefore, it becomes imperative to minimize sedentary behaviors among older adults, with a specific emphasis on individuals with disabilities.
Fear of falling emerges as a critical determinant influencing the likelihood of activity avoidance in community-dwelling older adults [8]. Extensive research has established that psychological factors are stronger predictors of physical performance in comparison to the actual demonstration of performance. Notably, a study conducted by J. Edgren et al. [9] affirmed the distinct nature of fear of falling and physical performance as separate variables, demonstrating that enhancing balance performance fails to inherently enhance confidence in balance. Moreover, the fear of falling exhibits a more robust correlation with the future risk of falling when juxtaposed with balance performance [9].
Depression and anxiety disorders are highly prevalent psychiatric conditions among individuals aged 65 years and above [10]. Recent research indicates that geriatric depression not only heightens the risk and mortality rates of various diseases but it is also consistently linked to poorer memory performance [11]. Moreover, patients with cognitive impairment, such as those who suffer from chronic cognitive impairment in their later years, are more susceptible to experiencing depression or anxiety. For instance, Ismail et al. [12] reported a high prevalence of depression among individuals with mild cognitive impairment. Investigations indicate that both subthreshold depression and depression itself can impair cognitive function. Furthermore, Sun et al. [13] established a significant negative correlation between the severity of depressive symptoms and attention/working memory capacity. Cognitive impairment has been shown to hinder the performance of daily activities. As cognitive functioning declines, the ability to carry out daily functions becomes increasingly compromised [1].
The living environment of elderly individuals plays a crucial role in their health, longevity, and quality of life [14]. Researchers argue that placing the elderly in care centers can reduce their control over their lifestyle and lead to physical, mental, emotional, and economic dependence on others. This dependence can threaten their social health and overall quality of life and undermine their dignity and well-being. In this regard, numerous studies show that elderly people who live with their families have higher levels of health and better quality of life. This can be attributed to the emotional support provided by family members, which creates a nurturing environment. Additionally, living in the community fosters valuable social connections between elderly individuals, their family, friends, and other community members, all of which contribute positively to their social well-being and overall quality of life [15]. In contrast, limited findings have addressed the positive impact of keeping the elderly in the care centers, which shows that the presence of the elderly in the centers helps them overcome their limitations. According to this group of researchers, staying in the care centers is a choice to adapt to a possible lack of resources and to provide various aspects of elderly life, and care centers can make the loss of functional capacity and independence bearable and compensate for the individual in some way. On the other hand, the benefits of living in the care centers include connection with peers, access to health, treatment, rehabilitation, and getting away from loneliness and depression, which can be effective in maintaining social health and quality of life for the elderly. Overall, the living environment of the elderly is an important vital factor [16, 17].
As evidenced by the aforementioned studies, the level of participation, disability, duration of physical activity, and contexts (personal and environmental) among the elderly are of significant importance. These factors exhibit a noteworthy correlation with the well-being and quality of life of the elderly, which are primary objectives in rehabilitation and care settings. Consequently, these factors deserve careful consideration within this population.
Determining the predictive role of various client factors becomes vital in understanding the performance of diverse client groups facing progressive and degenerative conditions. By assessing and monitoring the initial changes in client factors, such as cognitive and psychological conditions, it becomes possible to devise more comprehensive plans and interventions for these groups. These strategies aim to counteract the decline in conditions, particularly, in present study, in terms of participation, level of disability, and physical activity duration.
In this study, the main focus is to understand how participation levels, disability, and duration of physical activity interact with cognitive and psychological factors (i.e., depression, anxiety, and fear of falling) in community-dwelling older adults. The overall aim is to assess the predictive power of these factors to provide valuable insights that can guide the design of targeted interventions for older adults to develop more effective interventions for the elderly population in future planning.
2. Methods and Materials
2.1. Participants
In this cross-sectional and analytical study, a total of 150 community-dwelling older adults above the age of 65 (87 men, 63 women) were recruited through a straightforward nonrandomized method with a mean (±SD) age of 78.74 (±7.24). These elderly individuals live independently within the community, actively engage in outdoor activities such as shopping and administrative tasks, and experience the typical conditions related to aging. This research spanned 9 months in 2023 with sampling conducted between April and September 2023, in Tehran, Iran. To take part in the study, individuals had to meet the following criteria: (1) be community-dwelling older adults aged over 65 years, (2) possess an adequate level of cognitive functioning, with a Montreal Cognitive Assessment (MoCA) score ≥ 21, and (3) can read Persian. Those with neurological, orthopedic, or rheumatologically conditions were not included in the study. All participants provided their written consent to participate and were informed they could withdraw at any time should they choose not to continue. Data collection was conducted in a quiet room with an air temperature of 20°C–25°C from 9:00 a.m. to 1:00 p.m. at the school of rehabilitation sciences, Iran University of Medical Sciences in Tehran City. The study’s protocols received approval from the Ethics Committee of the Iran University of Medical Sciences [IR.IUMS.REC.1401.016].
2.2. Predictors and Outcomes
Psychological factors (i.e., anxiety, depression, and balance confidence) were assessed by the Hospital Anxiety and Depression Scale (HADS), Geriatric Depression Scale-15 (GDS-15), and Fullerton Advanced Balance (FAB), respectively. Additionally, cognitive function (measured by MoCA) and demographic characteristics (age, gender, marital status, lifestyle, number of children, education, job status, current diseases, medications, and use of walking aid) were assessed to predict levels of participation, disability, and duration of physical activity in elderly individuals living in the community. These outcomes were evaluated by Community Integration Questionnaire (CIQ), Modified Health Assessment Questionnaire (MHAQ), and activity time (below or above 150 min of moderate-intensity aerobic activity per week) [18], respectively.
2.3. Assessments
The HADS is a test to diagnose depression and anxiety in patients with medical illnesses. This scale contains 14 items that assess an individual’s level of anxiety and depression across two subscales (each with seven items). Each item is scored on a scale from 0 to 3 (0 = never, 1 = sometimes, and 2 = often, 3 = always). A higher score on this test indicates a higher level of anxiety and depression. The validation of this scale in Iran has been tested by Montazeri et al. [19], and its internal consistency has been reported with an alpha of 0.85. In this study, only the anxiety subscale was used.
The GDS-15 is a screening measure for depression among the elderly. The 15-question form is scored with “yes” (1) or “no” (0), with total scores ranging from 0 to 15. A total score of 0–4 indicates no depression, 5–10 indicates mild depression, and 11–15 indicates severe depression; thus, a score above 5 suggests the presence of depression. This test takes between 5 and 7 min to complete and can be self-administered or completed by an examiner. The Persian version of this scale has appropriate validity and reliability (Cronbach’s α: 0.9) in older adults living in the community [20].
The FAB scale is used to assess balance in community-dwelling older adults with a high level of functional performance. The test comprises 10 items that evaluate different dimensions of balance. It evaluates all three sensory, musculoskeletal, and neuromuscular systems that may be responsible for balance disturbances. One of the benefits of this test is its capability to assess high-level balance and predict falls in older adults with high functional performance. This scale has been translated into Persian and psychometrically (Cronbach’s α: 0.84) evaluated by Dr. Azad et al. [21].
The MoCA was created in 2005 to perform cognitive screening. In Iran, it was standardized and validated (internal consistency = 0.77) by Badakhshan et al. [22]. The test includes the assessment of visuospatial/executive function (5 points), naming (3 points), attention (2 points), language (2 points), delayed recall (5 points), and orientation (6 points). The total score ranges from 0 to 30, with lower scores indicating a lower level of cognition. The administration of the test takes ~10 min [22].
The CIQ is a questionnaire designed to assess restrictions in social roles and social interactions. There are two versions of the scale available: one for interviewing the patient and another for family use, which can be conducted over the phone. If the participant is unable to understand the questionnaire, a representative can read it to them and complete it on their behalf. It includes 15 items to assess community integration, which falls into three domains: (1) Home Integration domain—five items, (2) Social Integration domain—six items, and (3) Productivity domain—four items. Total scores can range from 0 to 29 with higher scores indicating greater independence. The completion time for this questionnaire ranges between 5 and10 min. The Persian version of this questionnaire was psychometrically (ICC ≥ 0.70) analyzed by Dr. Negahban et al. [23].
The Quick DASH-11 has been an assessment tool to gauge the level of disability and function of the upper limbs. It is completed and scored by the patients themselves. To calculate the total score, the responses are summed up and then divided by the number of items (11 items), then subtracted by 1, and finally multiplied by 25. Lower scores indicate a lower level of disability. The validation of this questionnaire in Iran demonstrated excellent correlation and excellent test–retest reliability (0.82) [24].
The MHAQ was modified in 1980 and includes 5 subscales. One of the subscales is the Disability Index containing eight dimensions, which was used in this study. This subscale determines the level of an individual’s disability on a scale of 0–3, where a higher score indicates greater disability. Scores of less than 0.3 are considered normal. It has been suggested that scores be categorized into mild (scores less than 1.3), moderate (scores between 1.3 and 1.8), and severe (scores above 1.8) disability. Each of the eight dimensions has only one question. This questionnaire includes items related to the ability to dress, enter and exit a bed, lift a full cup or glass to the mouth, walk on a flat surface, wash and dry the entire body, bend and pick up clothing from the ground, turn taps on and off, and get in and out of a car [25]. The Persian version was validated (Cronbach’s α: 0.98) by Rastmanesh et al. [26].
2.4. Statistical Analysis
To examine the normal distribution, the Kolmogorov–Smirnov test was used, and stepwise regression models were employed to explore the relationships between predictors and outcomes. To determine the appropriate factors for each model, the correlations between predictors and outcomes were initially assessed using Pearson’s correlation coefficient for parametric variables and Spearman’s for nonparametric variables, respectively. Only predictors with a significant relationship with any of the outcomes (i.e., participation, level of disability, and duration of physical activity) were included in the regression model. A significance level of 0.05 was considered.
3. Results
In this study, 150 elderly community-dwellers (87 men, 63 women) with an average age of 78.74 years participated. The demographic and clinical characteristics of the participants have been reported in Tables 1 and 2.
| Variables | Minimum | Maximum | Mean | Standard deviation | Significance level |
|---|---|---|---|---|---|
| Age (year) | 66 | 89 | 78.74 | 7.24 | < 0.001 |
| Children (n) | 0 | 6 | 2.99 | 1.20 | < 0.001 |
| MoCA (0–30) | 17 | 29 | 24.05 | 2.50 | < 0.001 |
| CIQ | |||||
| Home integration (0–10) | 1 | 10 | 6.40 | 2.06 | < 0.001 |
| Social integration (0–12) | 1 | 12 | 8.35 | 2.27 | < 0.001 |
| Productive activities (0–7) | 0 | 7 | 1.83 | 1.31 | < 0.001 |
| Total score (0–29) | 3 | 26 | 16.57 | 3.40 | < 0.001 |
| GDS-15 (0–15) | 0 | 14 | 3.96 | 3.08 | 0.014 |
| HADS (0–21) | 1 | 21 | 6.13 | 2.66 | < 0.001 |
| Quick-DASH-11 (0–100) | 0 | 88.63 | 20.19 | 16.67 | < 0.001 |
| MHAQ (0–3) | 0 | 1.50 | 0.39 | 0.42 | < 0.001 |
| FAB (0–40) | 4 | 39 | 24.05 | 7.20 | < 0.001 |
- Note: Quick-DASH, Shortened Disability of the Arm, Shoulder and Hand Questionnaire.
- Abbreviations: CIQ, Community Integration Questionnaire; FAB, Fullerton Advanced Balance Scale; GDS, Geriatric Depression Scale; HADS, Hospital Anxiety and Depression Scale; MHAQ, Modified Health Assessment Questionnaire; MoCA, Montreal Cognitive Assessment.
| Variables | N (%) |
|---|---|
| Gender | |
| Male | 87 (58%) |
| Female | 63 (42%) |
| Marital state | |
| Single | 120 (80%) |
| Married | 2 (1.3%) |
| Living arrangements | |
| Alone | 28 (18.7%) |
| With family/spouse | 122 (81.3%) |
| Level of education | |
| Below high school | 42 (28%) |
| Diploma | 44 (29.3%) |
| University degree | 64 (42.7%) |
| Job status | |
| Homemaker | 37 (24.7%) |
| Employed | 106 (70.7%) |
| Retired | 1 (0.7%) |
| Unemployed | 6 (4%) |
| Comorbid disease | |
| None | 38 (25.3%) |
| Cardiovascular | 20 (13.3%) |
| Metabolic | 23 (15.3%) |
| Multiple concurrent disease | 45 (30%) |
| Other disease | 24 (16%) |
| Drug usage | |
| Yes | 68 (45.3%) |
| No | 82 (54.7%) |
|
|
| Normal (26–30) | 50 (33.3%) |
| Mild (18–25) | 100 (66.7%) |
| Moderate (10–17) | 0 (0%) |
| Walking aid | |
| Yes | 21 (14%) |
| No | 129 (86%) |
| Physical activity time per weak | |
| Less than 150 min | 53 (35.3%) |
| More than 150 min | 97 (64.7%) |
| Disability state (MHAQ) (0–3) | |
| Normal (0–<0.3) | 82 (54.7%) |
| Mild (1.3–<1.3) | 64 (42.7%) |
| Moderate (1.3–<1.8) | 4 (2.7%) |
| Severe disability (1.8–3) | 0 (0%) |
| Geriatric Depression state (GDS-15) (0–15) | |
| No depression (0–4) | 100 (66.7%) |
| Mild (5–10) | 45 (30%) |
| Severe (11–15) | 5 (3.3%) |
| Hospital Anxiety Depression Scale (HADS) (0–21) | |
| Normal (0–7) | 123 (82%) |
| Mild (8–10) | 21 (14%) |
| Moderate (11–14) | 5 (3.3%) |
| Severe (15–21) | 1 (0.7%) |
| Falling risk (FAB) (0–40) | |
| Low risk (25–40) | 65 (43.3%) |
| High risk (0–24) | 85 (56.7%) |
| Fall history | |
| Yes | 23 (15.3%) |
| No | 127 (84.7%) |
- Abbreviations: FAB, Fullerton Advanced Balance Scale; GDS-15, Geriatric Depression Scale; HADS, Hospital Anxiety and Depression Scale; MHAQ, Modified Health Assessment Questionnaire; MoCA, Montreal Cognitive Assessment.
Correlation analysis by Pearson correlation coefficient revealed age (r = −0.30, p < 0.001), education level (r = 0.22, p = 0.008), job (r = 0.27, p = 0.001), use of walking aids (r = −0.40, p = 0.001), depression (r = −0.53, p < 0.001), upper limb function (r = −0.51, p < 0.001), balance (r = 0.60, p < 0.001), history of falling (r = −0.22, p = 0.007), and cognitive function (r = 0.57, p < 0.001) significantly associated with social participation.
Furthermore, the results showed that there is a significant relationship between age (r = 0.39, p < 0.001), education level (r = −0.26, p = 0.001), job (r = −0.32, p = 0.001), use of walking aids (r = 0.52, p < 0.001), depression (r = 0.52, p < 0.001), upper limb function (r = 0.63, p < 0.001), balance (r = −0.79, p < 0.001), history of falling (r = 0.35, p < 0.001), and cognitive function (r = −0.48, p < 0.001) with level of disability.
The findings revealed that there is a significant association between age (r = −0.17, p = 0.037), education level (r = 0.31, p < 0.001), job (r = 0.22, p = 0.006), use of walking aids (r = −0.31, p < 0.001), depression (r = −0.20, p = 0.014), upper limb function (r = −0.30, p < 0.001), balance (r = 0.33, p < 0.001), history of falling (r = −0.23, p = 0.005), and cognitive function (r = 0.36, p < 0.001) with duration of physical activity.
Additionally, a significant relationship was observed between anxiety with social participation (r = −0.36, p < 0.001) and level of disability (r = 0.26, p = 0.001). Moreover, there was a significant relationship between the level of disability with marital status (r = 0.27, p = 0.001), lifestyle (r = −0.29, p < 0.001), and drug use (r = 0.18, p = 0.029) and also between the duration of physical activity with gender (r = −0.16, p = 0.047). Finally, the control of confounding variables (age, gender, marital status, lifestyle, number of children, education, job, current diseases, medication, and walking aid) has been completed, and each significant variable was entered into the model (Table 3).
| Predictor | Outcomes | ||
|---|---|---|---|
CIQ Pearson (p-value) |
MHAQ Pearson (p-value) |
Activity time Pearson (p-value) |
|
| Age | −0.30 (< 0.001) | 0.39 (< 0.001) | −0.17 (0.037) |
| Gender | −0.03 (0.68) | 0.15 (0.076) | −0.16 (0.047) |
| Marital status | −0.11 (0.20) | 0.27 (0.001) | −012 (0.151) |
| Life style | 0.13 (0.102) | −0.29 (< 0.001) | 0.11 (0.176) |
| Children (n) | −0.03 (0.74) | 0.11 (0.20) | −0.02 (0.84) |
| Education | 0.22 (0.008) | −0.26 (0.001) | 0.31 (< 0.001) |
| Job | 0.27 (0.001) | −0.32 (< 0.001) | 0.22 (0.006) |
| Current diseases | −0.11 (0.17) | 0.15 (0.072) | −0.14 (0.095) |
| Drug | −0.12 (0.15) | 0.18 (0.029) | 0.085 (0.302) |
| Walking aid | −0.40 (0.001) | 0.52 (< 0.001) | −0.31 (< 0.001) |
| GDS-15 | −0.53 (< 0.001) | 0.52 (< 0.001) | −0.20 (0.014) |
| HADS (A) | −0.36 (< 0.001) | 0.26 (0.001) | −0.14 (0.083) |
| Quick DASH-11 | −0.51 (< 0.001) | 0.63 (< 0.001) | −0.30 (< 0.001) |
| FAB | 0.60 (< 0.001) | −0.79 (< 0.001) | 0.33 (< 0.001) |
| Fall history | −0.22 (0.007) | 0.35 (< 0.001) | −0.23 (0.005) |
| MoCA | 0.57 (< 0.001) | −0.48 (< 0.001) | 0.36 (< 0.001) |
- Note: QuickDASH-11, Shortened Disability of the Arm, Shoulder and Hand Questionnaire.
- Abbreviations: CIQ, Community Integration Questionnaire; FAB, Fullerton Advanced Scale; GDS-15: Geriatric Depression Scale; HADS (A): Hospital Anxiety and Depression Scale (Anxiety); MHAQ, Modified Health Assessment Questionnaire; MoCA, Montreal Cognitive Assessment.
The regression models explained 52% of the variance for social participation (R2 change = 5%, p < 0.001), 68.6% for the level of disability (R2 change = 1.40%, p = 0.011), and 18% for the duration of physical activity (R2 change = 4.50%, p = 0.005), indicating the predictive power of the models. In all stepwise regression models, balance, as measured by the FAB scale, was the strongest predictor for all three outcomes: participation, level of disability, and duration of physical activity.
Regarding participation, cognitive function assessed using the MoCA and depression measured by the GDS-15 were the second and third most influential predictors, contributing the most to the variance.
In determining the level of disability, the state of depression as measured by the GDS-15, the function of the upper extremities as assessed by the Quick DASH-11, and anxiety as evaluated by the HADS ranked as the second, third, and fourth most robust predictors, respectively, each accounting for a considerable portion of the variance.
For the duration of physical activity, the level of education emerged as the second strongest predictor with the highest variance (Table 4).
| Functional balance outcomes | Models/predictor | R2 (%) | R2 change (%) | p(v) |
|---|---|---|---|---|
| CIQ | Model 1: FAB | 36.00 | 36.00 | < 0.001 |
| Model 2: FAB + MoCA | 47.00 | 10.00 | < 0.001 | |
| Model 3: FAB + MoCA + GDS-15 | 52.00 | 5.00 | < 0.001 | |
| MHAQ | Model 1: FAB | 61.90 | 61.90 | < 0.001 |
| Model 2: FAB + GDS-15 | 66.00 | 4.20 | < 0.001 | |
| Model 3: FAB + GDS-15 + Quick DASH-11 | 67.20 | 1.20 | 0.024 | |
| Model 4: FAB + GDS-15 + Quick DASH-11 + HADS (A) | 68.60 | 1.40 | 0.011 | |
| Activity time | Model 1: FAB | 13.50 | 13.50 | < 0.001 |
| Model 2: FAB + Education | 18.00 | 4.50 | 0.005 | |
- Note: QuickDASH-11, Shortened Disability of the Arm, Shoulder and Hand Questionnaire.
- Abbreviations: CIQ, Community Integration Questionnaire; FAB, Fullerton Advanced Scale; GDS-15, Geriatric Depression Scale; HADS (A), Hospital Anxiety and Depression Scale (Anxiety); MHAQ, Modified Health Assessment Questionnaire; MoCA, Montreal Cognitive Assessment.
4. Discussion
The purpose of this study was to investigate the predictive role of some of the most prevalent psycho-cognitive issues (anxiety, depression, fear of falling, and cognitive level) in elderly individuals on their levels of participation, disability, and physical activity time. By understanding how these prevalent factors can predict the progression of functional conditions related to aging, we can improve diagnosis and planning, leading to better management of risks and prevention of decline in the quality of life for elders [27].
The study revealed that balance confidence (measured by FAB) emerged as the most influential predictor for participation, level of disability, and duration of physical activity. Balance confidence or fear of falling has been established as a strong predictor of future falls in various groups, particularly the elderly [28]. Falls can significantly impact the lives of this vulnerable group, leading to decreased participation, physical activity, and increased disability levels. Previous research has also examined the relationship between other predictive factors in this study, such as depression, anxiety, and cognitive issues, and their influence on balance confidence and fear of falling [29–31]. These findings demonstrated that depression, anxiety, and cognitive issues can exacerbate balance confidence in individuals. The identified associations between these factors and balance confidence may clarify why balance confidence emerged as the most powerful predictor for participation, disability level, and duration of physical activity in older adults.
In summary, the research identified cognitive performance (by MoCA) and depression (by GDS), as second and third predictors, respectively, for the level of participation among older adults. For predicting the level of disability (assessed by MHAQ), depression and upper limb function (assessed by Quick DASH-11) were key factors. Furthermore, education level emerged as a significant predictor for the duration of physical activity. These results suggest that to improve participation and hinder the disability of the elderly, besides the interventions related to increasing the balance confidence, cognitive exercises and paying attention to their depression status are also very important.
Additionally, elderly individuals with severe depression have twice the risk for cognitive dysfunction [32] and cognitive issues. As shown, it is the most powerful predictor for the level of participation after balance confidence. Depression can also reduce the level of social participation among the elderly. Wang et al. found that participation in friend-making, exercise, and recreational activities can significantly reduce the risk of depression in the elderly [33], and considering cognitive interventions besides could be really helpful.
Also, depression can increase the risk of incident disability in older persons. This excess risk is partly explained by depressed persons’ decreased social interaction and physical activity [34]. The quality of upper limb function could be closely related to the ability to perform activities of daily living, which could include various forms of physical activity. According to the results obtained, the quality of upper limb function emerged as the third significant predictor of disability levels among the elderly. Therefore, it should be taken into consideration in clinical and research settings. As individuals age, the function of their upper limbs decreases, which crucially impacts their independence and quality of life [35].
Furthermore, the educational level was the second predictor of physical activity time. As previously revealed, the educational level has a positive relation with time spent on physical activity. However, the relationship between education and physical activity can differ depending on the type of physical activity. For example, a study found that work-based physical activity was highest among adults with high school or some college education and was the lowest among college graduates or higher [36]. This suggests that while higher education may be associated with more leisure-time physical activity, it may be associated with less work-based physical activity.
These results confirm the importance of paying attention to the balance of confidence in this age group, and it is necessary to consider interventions in occupational therapy that focus on improving the performance of these individuals and increasing their quality of life. The balance confidence in this study was measured using the FAB tool, which had a significant negative correlation with the MHAQ tool. Since higher scores in the MHAQ indicate higher levels of disability, individuals who score higher in the FAB and therefore have a higher balance confidence will score lower in the MHAQ, indicating a lower level of disability. Additionally, the FAB had a significant positive correlation with the CIQ tool, meaning that individuals with a higher balance confidence also have greater social participation.
The depression measured by GDS-15 was identified as the second significant predictor for the level of disability and the third predictor for the level of participation. These results indicate that, in addition to addressing the level of balance confidence, depression issues require special attention, and it should be considered as one of the primary therapeutic goals for them. One possible reason for this finding could be the fact that the depression among community dwelling adults aged 65 years and older is estimated to be between 5% and 10% [37]. Additionally, it can have significant impacts on their physical, cognitive, and social functioning, which could ultimately cause disability in this population [38].
Furthermore, the cognitive level based on MoCA was recognized as the second most powerful predictor in this study for the level of social participation of these individuals. This suggests that cognitive exercises and improving cognitive function could enhance the participation of these individuals. Alongside physical issues, improving cognitive function could significantly help increase their participation in daily activities.
The upper limb function based on Quick DASH-11 and the level of anxiety based on HADS were identified as the third and fourth powerful predictors for assessing the level of disability, respectively. Similar to past studies examining the relationship between upper limb function or the presence of anxiety and the level of disability [35, 39 ].
Also, the results of the study showed that men had a longer duration of physical activity than women, which is consistent with Azevedo et al. and Stalling et al. studies [40, 41]. Lower maximum oxygen consumption, lower hemoglobin, lower blood volume, higher fat percentage, and lower muscle mass in women compared to men can be its causes. Therefore, in formulating treatment protocols, gender differences in the elderly should also be considered [42, 43].
The results of this study could contribute to improving the clinical insight of therapists. These findings can also be part of an intervention guideline to deal with this group of elderly people aged 65 years old and older living in the community, with high ability levels and without cognitive problems, so that we consider these individuals not only from a physical perspective but also from other mental and psychological aspects. This holistic approach can help us provide them with more comprehensive and holistic therapeutic goals and behaviors, ultimately improving their quality of life.
5. Conclusion
The study revealed that balance confidence emerged as the most influential predictor for participation, level of disability, and duration of physical activity in community-dwelling older adults. The second predictors for factors affecting participation, the level of disability, and the duration of physical activity were cognitive level, depression, and education level, respectively. Additionally, the third predictors identified for participation and the level of disability were the extent of depression and upper limb function, respectively. The fourth strong predictor was the presence of anxiety, which had a significant correlation with the level of disability among elderly individuals living in the community.In general, the occupational performance of elderly individuals is affected by the interaction of physical, cognitive, and psychological factors along with the living environment and personal factors.So, specialist therapists in the field of the elderly should assess the predictive power of these factors to provide valuable interventions for older adults and develop more effective goal-setting for the elderly population in future studies.
5.1. Study Limitations and Suggestions
There are some limitations to this study. First, although logistic and linear regression methods were valuable in identifying predictors of participation, time spent in physical activity, and disability status among aging individuals, such findings cannot imply causation due to their correlational basis. Second, the study’s focus was on examining these outcomes from an occupational therapy perspective, which underscores the potential benefits of exploring these outcomes within other disciplines and clinical contexts in future research. Third, since part of the sampling of this study was conducted during the Corona-19 pandemic and access to elderly people living in the community was limited, a simple and non-random method was used and future studies should consider employing probability sampling methods. Due to the preliminary cross-sectional study with small sample size, causal inference techniques, complex relationships, and the use of a longitudinal design to examine variable changes over time were not investigated, and future studies in the form of a cohort with a larger sample size are suggested. The participants were also exclusively community-dwelling, and those who could not walk independently outdoors or had severe diseases or cognitive impairments were excluded. Consequently, our findings may not be generalizable to older adults with specific pathologies, such as Parkinson’s disease or cerebrovascular accidents, and non-community residents.It is suggested that in future studies, the study population should be a combination of community-dwelling and non-community-dwelling elderly with different cognitive levels and that influential environmental factors, including air temperature and humidity, should also be considered.
Ethics Statement
Ethical approval was obtained from the Research Committee of the Rehabilitation Sciences Faculty, Iran University of Medical Sciences (IUMS) [IR.IUMS.REC.1401.016].
Conflicts of Interest
The authors declare no conflicts of interest.
Author Contributions
All authors read and approved the final version of the manuscript.
Funding
The authors received no specific funding for this work.
Acknowledgments
The authors would like to express their sincere gratitude to all the participants in this study and to the Iran University of Medical Sciences (IUMS).
Open Research
Data Availability Statement
All data used to support the results of this study are included in the article.
