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A SYSTEMATIC REVIEW ON FACTORS INFLUENCING THE HEALTHY AGING: A KOREAN PERSPECTIVE

 

J.H. Park, Y.J. Park

 

NutriEpigenomics Laboratory, Department of Nutritional Science and Food Management, College of Science and Industry Convergence, Ewha Womans University, Seoul, Republic of Korea

Corresponding Author: Yoon Jung Park, NutriEpigenomic Laboratory, Department of Nutritional Science and Food Management, Ewha Womans University, 52 Ewhayeodae-gil, Seodaemoon-gu, Seoul 03760, Korea, Rep. of. Telephone: 82-2-3277-6533, FAX: 82-2-3277-2862 E-mail: park.yoonjung@ewha.ac.kr

J Aging Res Clin Practice 2018;7:3-8
Published online February 15, 2018, http://dx.doi.org/10.14283/jarcp.2018.2

 

Abstract

An increasing number of researches on gerontology has emphasized an aging process without impairments of physical and/or cognitive function, alongside with an increase of life expectancy. However, studies to date on a healthy aging have suggested limited information on normal and usual aging in an inconsistent manner. Here, we review characteristics to define a healthy aging and, moreover, suggest effective elements to achieve the healthy aging through systematic review. Based on two databases including RISS and PUPMED, we collected original articles showing links between health-related traits and associated factors in Korean population aged 65 years or older. After screening the titles and abstracts, full texts of 186 articles were reviewed, and the remaining 109 papers meeting the inclusion criteria were analyzed to extract aging characteristics and factors of healthy aging. Here, we focus on two themes: 1) definition of a healthy aging and 2) effective determinants influencing the healthy aging. Our results suggest that a healthy aging is a multidisciplinary concept involving objective, subjective and comprehensive definitions. We classify the healthy aging-associated factors into physical, emotional, mental, social and economic domains, and identify that dietary patterns and nutrients among the multi-layer elements become good modifiable factor to achieve the healthy aging..

Keywords: Healthy aging, successful aging, midlife factors, Korean elderly.

 

Introduction

The progressive increase of life expectancy is a major epidemiologic issue we are facing. By the early 20th century, major causes of illness and death were infectious and parasitic diseases and, thus, a short life expectancy was accompanied by a low survival rate of children and the elderly who are easily infected from virus and bacteria (1). However, a dramatic increase of global life expectancy is being driven by the remarkable improvements of hygiene, nutrition and accessibility to medical care during the last century. According to the report of the World Health Organization, the global population of older adults aged 65 or older would be expected to increase from an estimated 524 million in 2010 to nearly 1.5 billion in 2050 (1). Alongside with the rapid aging, a transition of illness causing the world population to suffer has occurred from infectious diseases to non-communicable diseases such as obesity, diabetes, cardiovascular diseases and cancer. The high prevalence of chronic diseases raises the question whether the present population lives longer with maintaining their well-being status. A concept of well-being encompasses positive status of physical and emotional health, economic condition, social activity and life satisfaction (2). Thus, it is important to understand and strengthen well-being to provide a way for diseases prevention as well as comprehensive health promotion. However, the concept of well-being has a limitation to apply to the elderly specifically, due to the wide coverage of population. Thus, it becomes critical how to define a healthy aging in terms of well-controlled physical, mental and socioeconomic systems without illness in the elderly. To date, a term of successful aging has been widely used to define a healthy aging in a usual population. A model for the successful aging was proposed by Rowe and Kahn, for the first time, and this involves multidimensional domains which are similar elements of well-being (3). However, many studies have still offered inconsistent criteria to define an effective successful aging with diverse terminologies. Therefore, we aim to explore coherent characteristics organizing healthy and successful aging via a systematic review of clinical researches, particularly in Korean elderly. In addition, we investigate effective determinants contributing to the healthy aging at an individual level as well as social and national levels.

 

Methods

Search strategy

We searched articles on the Korean Research Information Service System (RISS) and the PubMed databases. We used search terms “elderly”, “aging”, “health” and “Korean” and searched articles published from 1995 to 2017. The search is processed by RISS as: “Korean” [All Fields] AND “elderly” [All Fields] AND “health” [All Fields] AND “aging” [All Fields]) and by PubMed as: (“Korean” [Title/Abstract] AND “elderly” [Title/Abstract] AND “Health” [Title/Abstract] AND “aging” [Title/Abstract]). In RISS database, domestic scientific journals and international journals were included and thesis, books and research reports were excluded. In PubMed database, every journal searched was included. Searching articles were conducted between January 5 and 17, 2017.

Figure 1 Flow of the selection process

Figure 1
Flow of the selection process

 

 

Study selection

Peer-reviewed journals conducted in the Korean elderly population aged 65 years or older were included. First, the titles and abstracts of the articles were screened according to inclusion and exclusion criteria as shown in Figure 1. Firstly, we excluded articles that were non-original articles, including review articles and conference publications, and were overlapped. Secondly, we excluded articles which did not match the research topic for healthy aging and the appropriate subjects such as participants who were non-Korean through reviewing titles and abstracts. Considering that the chronological age of 65 year is used to define elderly in Korea national reports such as Korea National Health and Nutrition Examination Survey and Dietary Reference Intakes for Koreans, we also excluded articles on the population under 65 years of age. After the screening, we reviewed the full-texts and extracted the finalized articles.

Data extraction

We extracted the following information from the included articles: (1) first author, (2) title, (3) published journal and year, (4) study design; (5) number of participants; (6) age of participants; (7) characteristics of aging outcomes; (8) and effective determinant influencing healthy aging (9). The extracted information was reviewed and categorized according to organizing criteria. Components of aging characteristics and factors affecting health status of the elderly from the included articles were categorized. Information regarding the Korean-specific aging was described with example articles in the text and discussion.

 

 

Results

Results of the literature search

Figure 1 shows the flow of article selection for systematic review. We searched initially four hundred fourteen articles in RISS (n = 307) and PUBMED (n = 107). The remained articles (n = 376) after removing duplicates (n = 38) were screened at titles and abstract levels. Full-texts of 186 articles were reviewed and 109 articles were included to extract data. The 109 articles comprised cross-sectional studies (n = 95), case-control studies (n = 0), nested case-control studies (n = 1), cohort (n = 12) and randomized control trials (n = 1). All the included researches were conducted in south Korea and every participant was the Korean elderly with age of 65 years or older.

Outcome characteristics to define aging in the Korean elderly

Few studies assess intervention or randomized control trial and, instead, cross-sectional and cohort. One study determined that the effect of exercise program on the improvement of health of the elderly through a randomized control. A variety of health characteristics to define aging were identified in the reviewed articles. The characteristics of health status of the elderly could be divided into objective and subjective criteria: the objective terms are defined by diagnosable characteristics such as mental and physical disorders and related-diseases, and the subjective characteristics are defined by self-reported ones such as perceived health and life satisfaction. The objective criteria could be classified into six subtypes; mortality, emotional disorders, mental functions, physical disorder, physical functions and molecular marker. Eighteen out of the 109 studies investigated emotional disorders including depression, suicide ideation or attempt, perceived stress and death anxiety. Ten studies investigated mental functions and related disorders including cognitive function, dementia, and Alzhimer’s disease. In relation to physical health, twenty-eight studies investigated physical diseases and the majority of the studies focused on metabolic diseases including obesity, sarcopenic obesity, glucose dysregulation and cardiovascular related-diseases as well as other physiological diseases including renal and pulmonary dysfunction, osteoarthritis, immune disorder and restless legs syndrome. Physical functions were investigated in sixteen studies in which six studies measured activities of daily living (ADL) and instrumental ADL (IADL), three studies assessed grip strength to evaluate functional ability of the elderly, and others investigated falls, frailty, hearing loss and oral health status to define physical functions. With regards to subjective criteria, self-reported characteristics were assessed by twenty studies. Eight studies evaluated self-rated health status which reflects simply an individual’s perception of general health status. Also, social participation activities and nutrient intakes were assessed through self-reporting scales by two and one studies, respectively.

Table 1 Classification of outcomes of aging reported in the included articles

Table 1
Classification of outcomes of aging reported in the included articles

 

In addition to the single elements in terms of objective and subjective criteria, twelves studies used comprehensive terms including ‘successful aging’, ‘health-related quality of life’ and ‘general health status’. Seven cross-sectional studies used the term ‘successful aging’ but the definitions could be divided into two concepts. A first concept of successful aging means psychological and social state by evaluating self-esteem, self-control, relationship with spouse and life satisfaction through success of children, which is suggested and defined by Kim and Shin (4). The other concept is based on the theory of human aging suggested by Rowe and Kahn, which encompasses diseases status, physical and mental functions and social activity (3). A term of ‘health-related quality of life’ contains physical function, mental health, emotional state and social participation were used in four cross-sectional literatures. A super-ordinate concept of ‘general health status’ embracing health-related quality of life and illness, geriatric depression, physical function was used in one article. These concepts are similar to the one of successful aging based on the Rowe and Kahn’s model.

Effective factors influencing healthy aging

Table 2 shows that healthy aging-associated factors are categorized into five; biological, mental, behavioral, nutritional and socioeconomic factors. Biological factors encompass physiological and biochemical factors. More specifically, physiological factors involve body composition, physical disabilities, pain, dental health including the number of missing teeth and denture wearing, dysphagia, auditory and visual impairments, renal function and anemia. These physiological factors are implicated to impact on comprehensive health status in the elderly as well as mortality (5-11). Biochemical factors are measurable in the blood and these consist of adiponectin, retinol binding protein (RBP) 4, vitamin D, thyroid-stimulating hormone (TSH), insulin-like growth factor (IGF) 1, insulin, lipids and serum anion gaps. The biochemical elements would be predictive factors of aging-related physical diseases. For instance, serum adiponectin, RBP4 and vitamin D levels are associated with prevalence of metabolic diseases (12-14). Serum TSH and cholesterol-related lipoprotein levels are risk factors of cognitive function (15) and sarcopenic obesity (16), respectively. Serum anion gap is a predictive factor of all-cause mortality (17). Factors categorized into mental health are stress, depression, sleep patterns, self-esteem, life satisfaction and cognitive function. These are associated with not only mental outcomes mentioned in the aging characteristics such as suicide ideation and memory capacity (18, 19) but also physical characteristics such as falls, frailty and urinary function (20-23). Behavioral factors reflecting individual life styles included physical activity, exercise, gait speed, alcohol consumption, smoking and polypharmacy, and were reported to be associated with the aging characteristics, mainly the prevalence of non-communicable diseases, physical function and emotional disorders and mortality (18, 24-28).

Table 2 Effective factors influencing healthy aging

Table 2
Effective factors influencing healthy aging

 

Associations between nutritional factors and healthy aging

In relation to nutritional factors, three cross-sectional studies provided that dietary intake and patterns, mainly affecting ratio of macro-nutrients, are associated with body composition and metabolic diseases in the aging characteristics. No, 2012, reported characteristics of healthy behaviors, particularly in dietary patterns of the Korean elderly by analyzing 2010 Korea National Health and Nutrition Examination Survey (KNHANES) (29). The Korean elderly highly consume carbohydrate and lower consumption of fat and vitamin C relative to the amount of daily nutritional allowance. When the population is classified into non-obese without metabolic syndrome (normal group), non-obese with metabolic syndrome, obese without metabolic syndrome and obese with metabolic syndrome, the obese groups exhibit a higher consumption of vitamin A, retinol and carotene, relative to the non-obese groups (29).
In addition, Oh et al. identified that dietary patterns in Korean elderly are differently associated with body composition changes, possibly affecting progression of non-communicable diseases (25). The elderly groups are classified into three groups according to their dietary patterns based on the consuming food groups; traditional Korean diet, meat and alcohol diet, and westernized Korean diet. Characteristics of the Korean traditional diet are high consumption of white rice and low consumption of meat, milk and dairy products, which may lead to low protein and calcium intakes. The meat and alcohol, and the westernized Korean groups fulfill their carbohydrate needs from other grains and flour-based foods such as noodle, dumpling and bread instead of white rice. The meat and alcohol diet group highly consumes meat and alcohol relative to other two groups and, thus, their intakes of protein and iron are also higher relative to other groups. Others excluding the traditional Korean diet group and the meat and alcohol group are assigned to the westernized Korean diet group. When comparing body compositions between the groups, the meat and alcohol group shows an increase of BMI and the westernized group shows an increase of Appendicular skeletal muscle / bodyweight (ASM/Wt). In other words, the Korean traditional diet has a lower ratio of muscle mass to bodyweight, relative to the westernized Korean diet. This probably leads to high risks against decline of physical function such as frailty, falls, ADL and instrumental ADL and, furthermore, age-related muscle wasting such as sarcopenia and sarcopenic obesity.
Regarding sarcopenic obesity, a cross-sectional study which was excluded due to the participants aged 60 or older reports that the prevalence of sarcopenic obesity is associated with consumption of energy and micronutrients in the Korean elderly (30). High intakes of carbohydrate in men and potassium in women decrease the likelihood of sarcopenic obesity in a gender-specific manner. Also, enough serum vitamin D levels decrease the prevalence of sarcopenic obesity both in men and women, but whether intake levels of vitamin D are also changed is unknown. This negative association between serum vitamin D levels and an onset of aging-related diseases was reported in another article showing links between deficiency of serum 25-hydroxyvitamin D (25-OHD) and stenosed coronary artery (31).

 

Discussion

This review suggests a comprehensive summary of evidence for the categorization of aging characteristics and probable factors in the Korean elderly. In our review of the 109 articles, characteristics to define an individual aging could be classified into objective traits such as diseases and functional declines and into subjective traits such as perceived health and life satisfaction. Only 9 studies provide multidimensional concepts to define healthy aging and, of the 9 studies, 4 articles use a concept of successful aging proposed by Rowe and Kahn, consisting of avoidance of diseases, maintenance of physical and cognitive function, and active social engagements (3). Moreover, the majority of studies conducted the survey through cross-sectional design while the studies based on the randomized control trial and cohorts were relatively scarce. Thus, multidisciplinary and prospective approaches to investigate causal relations between effective factors and healthy aging in Korean population more need to be considered in further studies.
Our findings provide classification of aging outcomes based on the domains of measurements into biological, mental, behavioral, nutritional and socioeconomic factors. Several determinants mutually influence in the included articles so that what was identified as a factor in some articles was assigned as an outcome in other researches. In many cases, physical elements such as functional disability and mental determinants such as geriatric depression and cognitive function affect each other (11, 21). Through the review regarding determinants to define a successful aging, we found the successful aging is significantly affected by gender and age in the Korean elderly (32). The female elderly has a lower probability to achieve successful aging, relative to male elderly, and the elderly older than 75 has a lower achievement than the elderly aged between 65 and 74. Given that South Korea shows the most rapid increase of aged population in the world, the negative effect of age on successful aging would be far greater in the following generation living in an aging society (1). Thus, we are facing an urgent need for a nation-wide effort to accomplish healthy aging through improving other modifiable determinants such as behavioral and socioeconomic supports. In this review, we suggest several nutritional determinants as modifiable elements influencing physical health such as body composition and onset of sarcopenic obesity. Therefore, based on this evidence, dietary intervention trials considering an excessive carbohydrate rate and/or a deficient vitamin D may improve the healthy aging in the Korean elderly.
In conclusion, we provide a step toward exploring a healthy aging in the Korean elderly. The healthy aging is a multidimensional concept embracing physical, mental and social domains. Physical function, social support, and behaviors including smoking and alcohol, and diet might contribute to the achievement of healthy aging. Further systematic review and meta-analysis in various populations following different ethnic as well as life styles and dietary patterns are needed to validate consistency of our findings and, moreover, further research on the prevention and/or intervention may help improve healthy aging in global population.

 

Funding: This study was supported by ILSI Korea.

Conflict of interest: Authors have no conflict of interest to disclose.

 

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PSYCHOMETRIC PROPERTIES OF THE ITALIAN VERSION OF RESILIENCE SCALE IN ADULTS AND ELDERLY HEALTHY SUBJECTS

N. Girtler1,2, F. De Carli3, J. Accardo1, D. Arnaldi1, M. Cutolo4, B. Dessi1, F. Famà1, M. Ferrara1, F. Nobili1, A. Picco1, A. Brugnolo1

 

1. Clinical Neurology, DINOGMI University of Genoa, Italy; 2. Clinical Psychology and Psychotherapy Unit, IRCCS San Martino – IST, Genoa, Italy; 3. Institute of Bioimaging and Molecular Physiology, Genoa Unit, National Research Council, Italy; 4. Clinical Rheumatology Unit, DIMI University of Genoa, Italy

Corresponding Author: Dr. Nicola Girtler Clinical Neurology, DINOGMI University of Genoa, Pad. Specialità piano fondi lato ponente, L.go R. Benzi 10 16132 Genova, Italy, Tel. +39 010 3537778, Fax +39 010 5556893, E-mail: nicolagirtler@unige.it

 

Abstract

Background: Resilience is a complex personality characteristic of people facing a significant change, adversity, distress, acute or chronic disease. The Wagnild and Young Resilience Scale is an appropriate instrument to study resilience and has been already validated in the Italian young-adult population. Objective: To verify psychometric properties of the Italian version of the RS scale in adults and elderly healthy subjects. Design: The participants filled out RS questionnaire; statistical analysis was performed to evaluate psychometric properties of the scale. Setting: University of Genoa: courses reserved for elderly people and Clinical Neurology outpatients’ department. Participants: 178 adults and elderly healthy subjects. Measurement: The Italian version of RS scale and three associate questionnaire (General Health Questionnaire, Ego-Resilience Scale, Beck Depression Inventory) were used to assess concurrent validity of RS, its reliability, stability, internal consistency and concurrent validity. Results: Time stability was assessed in a sub-sample of 48 subjects (Mean age = 68.89 yr, SD 7.54) by test-retest correlation (r=0.80). RS reliability was evaluated in the whole sample of 178 subjects (Mean age = 63.92 yr, SD 14.6) with an RS mean score of 138.43 (SD 14.6). Internal consistency was evaluated by Cronbach alpha (α=0.86). Concurrent validity was assessed by correlation with General Health Questionnaire (r=-0.45), Ego-Resilience Scale (r=0.59) and Beck Depression Inventory (r=-0.31). Principal component analysis resulted into six components, labelled according to the best association with the five components hypothesized by Wagnild and Young (i.e.: meaningfulness, self-reliance, perseverance, existential aloneness, equanimity a and b). Conclusion: Our data indicate that the Italian version of the RS scale is a reliable tool in the adults and elderly subjects in order to promote interventions and stress-management to improve resilience and facilitate successful aging.

 

Key words: Resilience scale, elderly, successful aging.

 

Introduction

Resilience is a multidimensional concept including a personal trait that protects people from psychiatric disorders and a dynamic process of adaptation to negative life events. Ahern et al (1) and Wagnild and Young (2) defined resilience as a personality characteristic that moderates the negative effects of stress and facilitates adaptation. Therefore, resilience is a complex personality characteristic and plays a notable role when people face a significant change, adversity, or distress.

Some features of resilience are optimism, trying to reach personal goals, sense of commitment to self, hardiness, effectiveness, strength, and self-esteem. Other relevant characteristics of resilience are patience and the ability to tolerate negative emotions. As a matter of fact, human capacity to adapt in the face of trauma, tragedy, adversity in general, and stressful life events can be defined as resilience. Regarding the elderly subjects, resilience is described as the ability to achieve, retain, or regain a level of physical or emotional health after illness or loss. Being resilient in advanced age is very important due to the common occurrence of adverse life events, physical changes associated with aging and various acute and chronic clinical issues. It is known that psychological and social problems can accelerate the development of disability, hospitalization, nursing home placement and death (3-6). Living with a chronic illness is stressful, therefore it is fundamental to consider the risk factors, the protective factors, the outcome of adaptation and the characteristics of resilience in adults who suffer from chronic disease. Some chronic conditions, such as rheumatoid arthritis, osteoarthritis and fibromyalgia, are known to have a negative impact on the quality of life, but the way in which patients cope with such conditions affects their long-term physical and psychological adaptation (7). Resilience may influence long-term physical and psychological functioning and adaptation under high stress condition of patients with rheumatic disorders (8). Mertens et al (9) found that a high level of resilience is significantly associated with physical, mental and social functioning in patients with type 2 diabetes or chronic obstructive pulmonary disease. Chronic pain also influences all aspects of life but resilient individuals with chronic pain recognize the value of remaining positive, accepting help and learning to live with the pain (10).

Among elderly subjects a good diet and physical activity are essential for the prevention of a number of health problems and they can also contribute to positive mental wellbeing. Moreover, the physiological, psychological, and social changes that often accompany aging can impair food intake resulting in poorer diet quality (11). As a matter of fact, chronic illnesses may further affect appetite and intake (12). In the same manner, despite the numerous age-related challenges to maintaining an active life and sufficient diet, some elderly people make efforts to meet these challenges thereby demonstrating resilience. Dietary resiliency is the ability to develop adaptive strategies to maintain an adequate diet despite facing dietary challenges. (13). Stewart Knox et al (14) studied the associations between obesity (BMI and waist circumference) and a number of biological and socio-demographic variables, including resilience, in two samples of English and Portuguese adult healthy subjects. They found that lower resilience was one among the variables that significantly predicted higher BMI in the Portuguese group or a larger waist circumference in the British group. Assuming that resilience determines how we respond to negative life experiences and hitches, the promotion of resilience could reduce vulnerability to life troubles. It is important for psychologists, physicians, nurses and other health care professionals to enhance resilience and to recognize the role of supporting adults and elderly subjects, especially if they live with chronic diseases.

To measure the construct of resilience, it is necessary to have an appropriate instrument. One of the most used tools to measure resilience is the Resilience Scale (RS) (2). In their review, Ahern et al (1) asserted that the RS was the most appropriate instrument to study resilience in adulthood as well as in the adolescent population. In a more recent review, the RS obtained a good rating in comparison with other analogous scales (15). This scale has been already translated from the original English version into several languages and the Italian version (16) of the RS has been validated in a sample of young adults. Wagnild and Young developed the RS for the purpose “to identify the degree of individual resilience, considered a positive personality characteristic that enhances individual adaptation”(2). They identified five components of resilience: 1) equanimity; 2) perseverance; 3) self-reliance 4) meaningfulness; 5) existential aloneness. The RS is a 25-item Likert scale using a 7- point rating (1 disagree – 7 agree): the score ranges from 25 to 175. In the Italian version (16) one item (item 11, “I seldom wonder what the point of it all is”) was excluded as outlier in internal consistency analysis. On the basis of approximated normal distribution, in this 24-item version, values of 141 or above were considered as indicating high resilience, values from 116 to 140 characterizing the mid-range, and values lower than 116 indicating low resilience.

The aim of the present study was to verify the stability, internal consistency and concurrent validity of the Italian version of the RS in a sample of adult subjects mainly focused on elderly people.

 

Methods

Design

This study analyses the data collected on a sample of voluntary healthy subjects and their relatives contacted during University courses reserved for elderly people who completed all scales and questionnaires used to validate the Italian version of RS.

Participants

178 out of 192 voluntary healthy subjects (111 females and 81 males) aged from 29 to 95 years (mean = 64.18 standard deviation – SD = 14.40) filled out all scales and questionnaires used to validate the Italian version of RS (16). They had their general medical histories carefully taken and underwent clinical examination. Exclusion criteria were previous or present neurological, psychiatric, metabolic or cardiovascular disorders.

According to the recommendations of the Helsinki Declaration of 1975, as revised in 2008, all subjects were informed about the objectives and methods of the research, and they agreed to take part in the study. The study was explained to all participants both orally and by written instructions; they completed the whole package scale in an average time of 20 minutes.

The test-retest reliability was evaluated in a sub- sample of 48 subjects (34 females and 14 males) aged from 50 to 88 years (mean = 68.89, SD = 7.54). They filled out the resilience questionnaire and then filled it out again about one month later.

Associated questionnaires

The 12-item Italian version (17) of the General Health Questionnaire (GHQ), the Italian version of the Ego-Resilience Scale (ER) (18) and the Italian version of the Beck Depression Inventory Second Edition (BDI-II) (19) were used to assess concurrent validity of RS. GHQ is a self-administered 12-item (4-point Likert scale: 0-3) questionnaire aimed at detecting minor psychiatric disorders. The overall score ranges from 0 to 36 with higher points indicating poorer health. The ER scale is composed of 14 items (7-point Likert scale: 1-7) measuring the subject’s capacity to conciliate his own needs and desires while respecting rules and other people. Higher points indicate good ego-resiliency. The BDI-II is a 21-item (4-point Likert scale: 0-3) self-report instrument intended to assess the existence and severity of symptoms of depression. Higher total BDI-II scores indicate more severe depressive symptoms. A positive correlation between RS and ER was expected; on the contrary, a negative correlation with RS was expected for GHQ and BDI.

Statistics

Reliability of RS was estimated by the test-retest procedure, evaluating the Pearson correlation coefficient between the first and second test, and by the internal consistency measure provided by Cronbach Alpha followed by the analysis of its components. Concurrent validity of RS was evaluated by computing the Pearson correlation coefficients between RS and the other three tests evaluating psychological health (GHQ), ego-resiliency (ER) and depression (BDI-II). The effect of age and sex on the total score at the four tests was evaluated by general-linear-model analysis. The structure of RS was further explored by factor analysis, where factors were identified by principal component analysis and rotated by varimax method to optimize the separation between factors. Only the factors explaining a portion of variance greater than the mean variance of the original variables were entered into the analysis (Kaiser criterion: eigenvalues greater than 1.0) were considered. Statistical analysis was performed by means of the Statistica software (StatSoft Inc., Tulsa, OK; http://www.statsoft.com/).

 

Results

The RS mean score in the test-retest sample was141.10 (SD = 13.37, range: 98-162) at T1and 141.64 (SD = 14.00, range: 105-164) at T2. The test-retest correlation was 0.80 (R2 = 0.64, p<0.0001). The RS mean score in the test-retest sample (# = 48, mean age = 68.89, mean RS = 141.37, SD = 12.97) was not significantly different from the mean score in the single-test group (# = 130, mean age = 62.09, mean RS = 137.35, SD = 15.06, t = -1.64). The RS mean score in the whole study sample was 138.43 (SD = 14.60, range 93–168). As for data distribution compared with standard reference values, 8.4% of the sample could be classified as low resilient individuals (score <116), 48.9% as high resilient (score >140) while the remaining 42.7% was in the mid-range. RS correlations were -0.45 with GHQ, 0.59 with ER and -0.31 with BDI (see Table 1 and 2 for details), all being statistically significant at p<0.0001. Internal consistency reliability of RS, as evaluated by Cronbach alpha, was 0.86; the correlation of each item with the total score was in the range 0.13-0. 66 and was greater than 0.4 for 18 out of the 24 items. The correlation between each item and the total score is reported in Table 3 along with mean item score and Cronbach alpha as evaluated after deleting the current item. Three items (#11, 19 and 21) were associated, if deleted, to an increase of Cronbach alpha indicating a poor contribution to the overall common factor underlying the RS also in agreement with their low item-total correlation. There was a significant positive relationship between age and resilience (r2 = 0.041, F1,190 = 7.46, p<0.0001): mean increasing rate of RS score was 0.202 per year. A significant difference between genders, but non-significant effect of age, was found for GHQ (F1,177 = 19.33, p<0.0001) and BDI (F1,177 = 14.88, p<0.0001), with higher values (poorer health) for females. No significant effects of age and gender on ER were found in this adult sample.

Principal component analysis resulted (according to the Kaiser criterion) into six components with eigenvalues greater than 1: these six components, altogether explaining 57.1% of total variance, were retained for factor analysis. Final communality estimates, representing the (relative) variance explained by the model for each item, ranged from 0.36 (item 18) to 0.72 (item 21). Factor loadings, representing item-factor correlation, overcame the conventional threshold, set at 0.4, for at least one factor for all items but one, item 3, which however reached the value 0.39. The first factor of principal component analysis accounted for 26.9% of total variance and was the most correlated with 18 out of 24 items. Following varimax rotation, explained variance and factor loadings were more evenly distributed between factors and the loadings overcame a 0.4 threshold for 23 out of 24 items: the maximum factor loading for item 18 was slightly lower than the threshold value (0.30). The association between items and factors, based on maximum factor loading, reached by each item, is reported in Table 4, in which the best fitting labels, among the five generally used in resilience theory, are reported for each factor. One item (14) contained double loadings, as the threshold value was exceeded in 2 factors. Two items (11 and 21) were apart associated to two specific factors, in agreement with their low correlation with total score, as highlighted by Cronbach analysis.

Table 1 Descriptive statistics for male and female subjects and for whole group are reported for each scale

Table 1: Descriptive statistics for male and female subjects and for whole group are reported for each scale

Abbreviations: RS, Resilience Scale; GHQ, General Health Questionnaire; ER, Ego-Resilience Scale; BDI-II, Beck Depression Inventory – II. * The asterisk indicates a significant difference between males and females (p < 0.001).

 

Table 2 Pearson correlation coefficients between resilience (RS) and concurrent scales

Table 2: Pearson correlation coefficients between resilience (RS) and concurrent scales

Significance levels: *: p < 0.02 ; **: p < 0.001; ***: p < 0.0001; Negative correlations indicate variations in the opposite directions (due to different definitions of the score with respect to well-being).

 

Table 3 Correlation analysis evaluating internal consistency of Resilience Scale (RS, 24-items Italian version) by Cronbach alpha

Table 3: Correlation analysis evaluating internal consistency of Resilience Scale (RS, 24-items Italian version) by Cronbach alpha

Overall value of Cronbach alpha was 0.86. Data reported in each column are: item identifier, number of valid data, mean score, correlation between the current item and the total score and Cronbach alpha as evaluated after elimination of the current item.

 

Table 4 Factor Analysis: factor loadings of each item of the Resilience Scale on selected factors

Table 4: Factor Analysis: factor loadings of each item of the Resilience Scale on selected factors

Six factors were selected according with the Kaiser criterion (eigenvalues greater than 1.0). Factor loadings exceeding the threshold, set at 0.4, are reported for all items but item 18, which does not reach the threshold and for which the maximum loading is reported. The items are grouped according to the factors they are associated to. Each factor has been associated with the best fitting label among the five generally used in resilience theory.

 

Discussion

The test-retest reliability, internal consistency reliability and concurrent validity of the Italian version of the RS, as applied to a sample of adult subjects, were consistent with data reported in the literature (20, 21) and, although slightly lower, with the Italian validation applied to a sample of young adults (16). The present study was mainly focused on resilience in elderly people but a larger age span was considered in order to find out age-related trends.

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The mean value of RS in our study group was 138.43, without significant difference between the single-test group and test-retest group. These values were comparable to those reported in the paper by Wagnild and Young (2) which were a bit higher (mean = 147.91, SD = 16.85) because the RS had 25 items instead of 24 (their mean value can be proportionally reduced to 142.0 ± 16.18). In our sample we found a positive effect of age on RS (0.202 RS units per year) that is not significantly different from the one reported by Lundman et al (20), equal to 0.134 RS units per year; no relationship with age was found in the previous Italian study on resilience in young – adults (16), probably due to the narrow age range. The mean value in that sample (126.6 ± 17.4) was slightly lower than expected from the present fitting, confirming the increase of RS with age and suggesting a stronger decrease in younger people. This trend is also stressed by the percent of people falling in the lowresilience range: it was 8.4% in the present study (48.9 and 42.7% respectively for the high and middle resilience range) but it was 32.5% in the Italian validation on young – adult sample (16). Wagnild and Young (2) and, more recently, Jeste et al (22) proposed that resilience correlates with positive aspects of successful aging. Our findings that resilience increases with age could depend on the processes developing during the life span which are probably influenced by several protective factors (23). According to, Lundman et al (20) and Celexa generic Girtler et al (16) we did not find an effect of gender on RS values. On the other hand, we found a significant gender difference for GHQ and BDI which showed higher values (poorer health) for females, in agreement with a number of studies concerning general health and depression (24). As for time stability, the correlation coefficient for the testretest was 0.80, close to the result obtained by Wagnild and Young (0.81; (2)) and to the correlation reported in the Swedish (0.78; (20)) and Italian (0.78; (16)) validation studies. The value of Cronbach alpha (0.86) confirmed the internal consistency of the Italian version of RS in adults and elderly sample, being in accordance with consistency evaluations reported in the recent review by Wagnild (21) and in the Italian validation (16). The concurrent validity was supported, although more slightly respect to the previous study on Italian sample of young-adults (16), by the highly significant correlation with three well established measures of the constructs linked with resilience, namely GHQ for psychological well-being, ER for flexibility in impulse control and a BDI-II for depression. These findings were in agreement with previous validation studies which found highly significant correlation between the RS and other recognized measures of well-being and an inverse correlation with depression (1).

Features of resilience were further explored by factor analysis. In designing the questionnaire Wagnild and Young (2) considered five component of resilience but only two clear components were supported by factor analysis in their original study.

A five-factor and a six-factor solution were found, respectively, in the Swedish version (20) and Italian version (16) of RS and these factors were related to the components of resilience construct.

Also in this sample, principal component analysis resulted into six factors. These factors were labeled looking for the best accordance with the five components hypothesized by Wagnild and Young: as in our previous study (16), factors 5 and 6 were both associated with equanimity, the first one expressing the ability to deal with external obstacles and the second one indicating a pragmatic approach in addressing life events. One item had double loading. Item 14 loaded in the factors “perseverance” and “existential aloneness” which could reflect the interaction of these components (the ability to remain involved and the awareness that certain situation must be faced alone).

On the whole, the correspondence between the percent of items assigned to the same factor in the present study and in the young-adult study (16) was 14/24 (58%) while with respect to the Swedish study (20) it was 9/24 (38%). The factor structure found in our study confirm that RS is a relatively homogeneous construct, with a strong common factor, as confirmed by Cronbach alpha, in which however some underlying interacting components can be distinguished and can be related to the original theoretical model. On the other hand, the low level of correspondence in the groups of items found by factor analysis in the different studies indicates that the association between some items and particular components of resilience is not so strong and the interpretation of these items may be influenced by different socio-cultural factors. Further studies with larger samples are needed to clear this point.

Our data indicate that the 24-item Italian version of the RS can be considered as a useful and reliable tool to measure resilience in the Italian adult population.

The analysis of resilience and its components may provide information about productive and effective strategies people can apply to cope with adverse condition such as in the face of a chronic disease or age- related impairments. As a matter of fact, resilience has been shown to play a protective role in patients with rheumatic conditions (25). Evers et al (8) in their review claim that “resilience interventions can improve patients’ long-term functioning, and seem to be especially useful when tailored to the specific risk and resilience factors of individual patients”. They also claimed that a prerequisite for developing effective treatments is knowledge of possible risk and resilience factors that predict the long-term physical and psychological functioning of patients.

Furthermore, high levels of acceptance of pain and coping and emotional distress (26) are associated with resilience characteristics.

The concept of resilience is also linked to the maintenance of adequate nutrition and it is known that adequate nutrition, especially in the elderly, is closely associated with well-being. Vesnaver et al (13) studied age-related problems with eating in a group of old subjects. They used semi-structured interviews to show how adequate strategies could be adopted to overcome eating-related difficulties. Applying by oneself to keep eating well or getting help when needed were pointed out as important components of dietary resilience. In another study Tiainen K et al (27) found that resilience was associated generic zoloft with favorable health behaviors, such as exercising more, smoking less, and consuming more portions of fruits and vegetables a day and drinking less alcohol. Perna et al (28) assess resilience by a short version of RS in a cohort of elderly subjects. They investigated whether resilience is positively associated with health behavior in an elderly population and whether this association differs in different socioeconomic groups. They found that resilient people were more likely to consume more servings of fruit and vegetables a day and to perform high/moderate physical activity as compared to non-resilient people. These studies show that validated screening instruments are becoming increasingly useful in clinical practice to identify and select patients at risk.

The RS seems to be a reliable tool to assess resilience in adult and particularly in elderly subjects. As a matter of fact, Resnick and Inguito (29) found an adequate reliability and validity of RS for evaluating elderly people with multiple comorbidities.

In conclusion, knowing the characteristics of resilience of adults and elderly subjects with or without a chronic diseases could be useful for the identification of people needing an intervention designed to improve resilience and coping skills to ameliorate their quality of life.

Very recently the international Consensus Group on “Cognitive Frailty”, an heterogeneous clinical manifestation characterized by the simultaneous presence of both physical frailty and cognitive impairment, has proposed potential preventive interventions that include the promotion of emotional resilience to improve well- being and the quality of daily life (30).

Resilience interventions and stress-management offer promising ways to improve the long-term functioning of adults and elderly subjects with or without chronic diseases.

In summary, we have validated in the Italian language the RS in an adult-elderly population which may be used to assess resilience in order to adopt preventive and treatment strategies in the adult-elderly people, especially in those with chronic diseases.

 

Conflict of Interest statement: All authors state that they have no conflicts of interest.

Ethical standards: This study complies with the current laws of Italy.

 

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