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Abstract

The aim of this study is to investigate whether there are associations between physical fitness and loneliness in older adults, and whether these associations are mediated by psychological distress, an important factor which remains still controversial in this population. One hundred and thirteen older adults (71.71 ± 6.66 years; 75 women), were evaluated of physical fitness (cardiorespiratory fitness, balance, and upper limb strength), loneliness, and psychological distress (depression, anxiety, and stress). Independent mediation analyses were run with PROCESS macro for SPSS. Cardiorespiratory fitness, balance, and upper limb strength significantly and negatively predicted depression (all P < 0.050). Balance predicted significantly and negatively anxiety (P < 0.050). Depression predicted significantly and positively loneliness. Although we did not find any direct effect between physical fitness and loneliness, mediation analyses indicated that lower levels of cardiorespiratory fitness, balance and upper limb strength were associated with higher loneliness via higher levels of depression. These findings support the idea that psychological distress (particularly depression) has an important role in the link between physical fitness and loneliness in older adults.

Keywords

isolation physical health depression anxiety stress aging

“Depression was a common significant mediator in the relationship between cardiorespiratory fitness, balance and upper limb strength with loneliness.”

Introduction

Loneliness is defined as an unpleasant experience of a discrepancy between one’s desired and actual network of social relationships.¹ This negative feeling tends to increase with age² with prevalence data around 25-30% in older adults (individuals aged 60 and older),^3,4 which makes it a relevant problem because of the number of people affected, but also because of the negative consequences on health.

In line with this, previous research has suggested that loneliness is associated with a poorer perceived health,⁵ and a high risk for cardiovascular disease.⁶ But the importance of loneliness in older adults has been centered on the associations established with mental health problems such as psychological distress (including anxiety, depression, and stress symptoms).⁷ For example, some studies have shown that the association between loneliness and depression is bidirectional but stronger and more robust for depression as the initial symptom.⁸ Similarly, Domènech-Abella et al.⁹ found a longitudinal association between experiencing loneliness and higher likelihood of suffering from an anxiety disorder 2 years later. In the same way, other studies have reported that loneliness and perceived stress mutually predict each other over time.¹⁰

In this context, regular physical activity has emerged as a strategy able to mitigate loneliness and mental health problems.^11-14 The importance of physical activity is explained because it increases and/or preserves levels of functionality and physical fitness. Physical fitness can be defined as having the strength, balance, cardiorespiratory fitness, mobility, and coordination necessary for performing activities of daily living, thus allowing for physical independence and preserved quality of life.^15,16 Physical fitness is an important marker of health in aging,^17,18 and lower levels of physical fitness may contribute to loneliness through reduced capability to join in common social activities such as going out with friends, visiting relatives or traveling. However, there is still a scarcity of studies that look at the possible links between levels of physical fitness and feelings of loneliness. A prospective cohort study found that decrease in upper limb strength may be independently associated with a modest increase in loneliness among men below the age of 80 years.¹⁹ Another interesting study found that cardiorespiratory fitness was the most efficient variable as loneliness predictor, followed by upper limb strength.²⁰ These studies highlight the importance of physical fitness in older adults in reducing their loneliness risk. Conversely, other authors found no relationship between physical fitness and loneliness status.²¹ Therefore, these conflicting findings point out the need to go deeper into this topic.

On the other hand, physical fitness is also a strong predictor of mental health in older adults.²² In this regard, recent evidence has shown the important protective role of physical fitness on psychological distress in aging. For instance, the systematic review of Kandola et al.²³ found a longitudinal association between cardiorespiratory fitness and the risk of depression and anxiety. Zasadska et al.²⁴ demonstrated a relationship between low muscle strength measured with the handgrip strength test and intensified depressive symptoms in older population. Likewise, other authors have reported that the 5 times sit-to-stand test—a measure to assess lower limb strength—is a predictive tool for depression in older adults.²⁵ Moreover, impaired body balance is among the most common causes of falls and negatively influence psychological distress.^26,27

Summarizing, both physical fitness and loneliness are related to psychological distress in aging, but the association between physical fitness and this feeling of loneliness is still controversial. Thus, we tested a mediational theoretical model (Figure 1) in which we hypothesized that physical fitness would have an indirect impact on loneliness trough the effect on psychological distress (i.e., depression, anxiety, and stress). To the best of our knowledge, no studies have investigated this model before in older adults.

Figure 1.

Graphic of the hypothesized mediation model.

Methods

Data Source and Study Population

A total of 130 older adults participated in this study. They were recruited through a local public university and public health care facilities in Valencia, Spain (from September 2022 and September 2023). Recruitment was based on a medical derivation regarding the following criteria: aged 60 years or older and able to participate in 1 session of physical exercise. Exclusion criteria were presence of any disorder that would prevent physical activity, and present at least a 24-point cut-off in the Mini Mental State Examination²⁸ since participants needed a minimum cognitive status to face the questionnaires and functional test. Based on meeting these criteria, all participants received information from their primary care physician about their participation in a research program. Seventeen individuals did not meet the inclusion/exclusion criteria. Ultimately, a total of 113 participants (71.718 ± 6.66 years; 75 women) were included in the statistical analyses.

The study adopted a cross-sectional design with 2 days of data collection separated by about 48 hours. Blood pressure, oxygen saturation and heart rate were measured on both days, after 10 minutes of rest. For the final analysis, the average of the 2 days was taken. The first day of assessment included height and body composition by bioimpedance followed by the questionnaires of cognitive status, loneliness, and psychological distress. Finally upper limb strength was assessed. On the second day, participants were evaluated for balance, lower limb strength and cardiorespiratory fitness. All measurements were performed under standardized conditions and testing sessions were scheduled at similar time of the day for each participant in fasting conditions to minimize potential effects of diurnal variation.²⁹

All participants were informed about the experimental procedure and signed the written consent of this study that complies with the ethical standards of the Declaration of Helsinki 2013 and was approved by the ethics committee of the Hospital Clinico Universitario INCLIVA.

Independent Variables

Physical Fitness was Assessed Through the Following Tests

Cardiorespiratory fitness: Cardiorespiratory fitness was assessed with the 200-meter walking test (200MWT) which consist of walking twice up and down in a corridor of 50 m as rapidly as possible, without running. Slow-down and stops for resting were authorized.³⁰ The time elapsed was measured in seconds (s) at the end of 200m and the mean gait speed in m/s was calculated and considered for the statistical analysis.

Balance: Balance was assessed by mini-BEST test in its Spanish version (https://www.bestest.us/test_copies). According to O´Hoski et al.,³¹ the mini-BEST test assess dynamic balance through 14-item that includes 4 domains: anticipatory postural adjustments, postural responses, sensory orientation, and stability in gait. Score ranged from 0 to 2 in each item. Total score is 28 and higher scores indicate better balance. The total score of this test was used in the analysis.³¹

Upper limb strength: Upper limb strength was measured using the handgrip test with the Takei 5401 adaptive dynamometer (Takei Scientific Instruments Co). Participants were asked to squeeze the dynamometer with the hand as hard as possible for at least 5s in a standing position with full elbow extension. Three measurements were taken on each arm with a one-minute rest, while maintaining the force for 5 seconds, and the mean value of the best score of both arms was taken for statistical analysis.

Lower limb strength: The 5 times sit-to-stand test (5STS) was used to assess lower limb strength.³² Participants were instructed to cross both arms across their chest and stand up completely, then sit and stand up a total of 5 times as quickly and safely as possible. Timing began when the subject’s buttocks took off from the seat and stopped when they returned to the seat after the fifth repetition, thus less time to perform the test means better strength capacity. The test was performed once.

Dependent Variables

Loneliness: The Spanish version of the Revised UCLA Loneliness Scale (R-UCLA)³³ was used to assess general loneliness and degree of satisfaction with one’s social network. The R-UCLA has 20 items rated on a scale of 1 (never), 2 (rarely), 3 (sometimes), and 4 (often). Examples of the items are, “I lack companionship” and “I feel in tune with the people around me.” After reverse scoring appropriate items, loneliness scores were calculated by summing all items. The range of possible scores is 20 to 80, with higher scores signifying greater loneliness. Cronbach’s alpha for this measure was 0.83.

Mediation Variables

Psychological distress: The Spanish version of the Depression, Anxiety, and Stress Scale-21 (DASS-21) was used to evaluate psychological distress.³⁴ It consists of 21-items with 7 questions dedicated to each negative emotional state. The items are scored on a 4-point response scale with 0 = did not apply to me at all, 1 = applied to me to some degree/some of the time, 2 = applied to me to a considerable degree/a good part of time and 3 = applied to me very much/most of the time. Total scores are calculated for each psychological state with higher scores specifying more severe depressive, anxiety, or stress symptoms. Cronbach’s alpha for the depressive symptoms scale was 0.89, for anxiety was 0.82, and for stress was 0.88.

Other Variables

On both days, as soon as they arrived at the facility where the tests were carried out, the participants rested for 10 minutes in a chair. Arterial oxygen saturation (SpO2) and Heart Rate (HR) were determined with a pulse-oximeter attached in the middle finger of the left hand (WristOx2-3150; Nonin, Plymouth, MN, USA), in a sitting position. Blood pressure was also measured 3 times on the left arm with the arm tensiometer Omron M3 Intellisense (HEM-7051-E) (Omron Health care, Kyoto, Japan). In addition, we retained the mean values of systolic and diastolic blood pressure (SBP, DBP) to characterize the sample. On first day and after these assessments, height was assessed with a stadimeter (SECA222) and body weight was measured by bioimpedance (TANITA, model BC-545N, Tokyo, Japan), on fasting conditions with the participants lightly dressed and without shoes. Body Mass Index (BMI) was calculated as weight/height squared (kg/m2).

Statistical Analysis

We performed the data analysis using SPSS v. 27 (IBM Corp, 2020; Armonk, NY, USA) employing a statistical significance at P < 0.05. Descriptive analyses were calculated to describe the sample characteristics. The missing values of the item questionnaires were replaced by the item dimension means (2 missing values for DASS-21; 1 for depression and 1 for stress), or the total score mean (6 missing values for the R-UCLA). A post-hoc power analysis was conducted to evaluate whether the sample size was sufficient for testing the hypothesized model adequately. To this end, the achieved power to detect misspecification of a model with a sample size of n = 113, and df = 111 was calculated for the corresponding to Root Mean Square Error of Approximation = 0.06 on an alpha error of 0.05. This post-hoc was conducted with a semPower package in R. Concerning the hypothesized model (Figure 1), we tested the mediation model, assessing psychological distress (i.e., depression, anxiety, and stress) as the mediator in the relationship between physical fitness and loneliness, using the PROCESS macro³⁵ with 5000 bootstrap samples and unstandardized regression coefficients (model 4).³⁶ Independent mediations were run for every physical fitness variable. All the effects were evaluated through 95% bias-corrected confidence intervals (CIs). Effects were considered significant if their confidence intervals did not include zero.

Results

The post-hoc power analysis showed that sample size (n = 113) is associated with a power = 0.83 to reject a wrong model.³⁶ The characteristics of the participants are shown in table 1. The mean age of the participants was 71.718 ± 6.66 years, classified as overweight, well cognitive-status and high-normal blood pressure older adults. Regarding cardiorespiratory fitness, participants achieved a mean walk speed during 200-m above 1 m/s, a minimum speed to be considered independent and non-frail older adults. In general, participants showed low levels of loneliness, as well as low levels of depressive, anxiety, and stress symptoms.

Table 1.

Participant Characteristics.

	Mean (SD)
Age (years)	71.718 (6.66)
Cognitive status (score 0-30)	27.480 (1.83)
HR (ppm)	73.730 (11.84)
SpO2 (%)	95.597 (1.35)
SBP (mmHg)	130.252 (15.46)
DBP (mmHg)	78.526 (9.81)
BMI (score)	28.436 (4.73)
Cardiorespiratory fitness (m/s)	1.502 (0.24)
Balance (score 0-28)	20.580 (3.65)
Upper limb strength (kg)	25.576 (8.11)
Lower limb strength (s)	11.226 (2.51)
Depression (score 0-21)	3.966 (4.57)
Anxiety (score 0-21)	3.150 (3.73)
Stress (score 0-21)	4.988 (4.62)
Loneliness (score 20-80)	33.920 (8.60)

HR: Heart Rate; SpO2: Arterial oxygen saturation; SBP: Systolic Blood Pressure; DBP: Diastolic Blood Pressure; BMI: Body Mass Index; SD: Standard Deviation.

Results of Pearson correlations (table 2) showed that almost all physical fitness variables (i.e., cardiorespiratory fitness, balance, and upper limb strength) are negatively and significantly correlated with depression. Moreover, balance was negatively and significantly correlated with anxiety. Unexpectedly, lower limb strength was no associated with psychological distress or loneliness. Loneliness, instead, was positively related to psychological distress (i.e., depression, anxiety, and stress) but no associations were found between loneliness and physical fitness variables. As expectedly almost all physical fitness measures were correlated within them, as well as psychological distress variables.

Table 2.

Pearson Associations Between Key Variables of Study.

	1	2	3	4	5	6	7	8
1. CF	-
2. Balance	0.684**	-
3. Upper limb strength	0.402**	0.494**	-
4. Lower limb strength	−0.441**	−0.431**	−0.147	-
5. Depression	−0.191*	−0.194*	−0.241*	0.081	-
6. Anxiety	−0.177	−0.242**	−0.082	0.134	0.746**	-
7. Stress	−0.084	−0.125	−0.114	0.057	0.789**	0.788**	-
8. Loneliness	−0.161	−0.101	−0.123	0.098	0.595**	0.485**	0.453**	-

CF: Cardiorespiratory fitness. **P < 0.01, and *P < 0.05.

Although we found no significant correlations between physical fitness variables and loneliness, this is not a rigid requirement to establish the existence of an indirect effect.³⁷ Therefore, we proceeded to test the hypothesized model. To test whether psychological distress variables (i.e., depression, anxiety, and stress) could mediate the relation between physical fitness variables (cardiorespiratory fitness, balance, upper limb strength, and lower limb strength) and loneliness, mediation models were tested separately.

Regarding the direct effects, cardiorespiratory fitness, balance, and upper limb strength significantly and negatively predicted depression (see Figure 2A,2B, and 2C). Besides, balance also predicted significantly and negatively anxiety. However, we did not find any direct effect between lower limb strength and psychological distress indicators. Among psychological distress variables, only depression predicted significantly and positively loneliness (Figure 2C). Lastly, no direct effects were observed between physical fitness and loneliness.

Figure 2.

Mediation models for the effect of physical fitness on loneliness, mediated by psychological distress. Significant effects are linked with continuous lines and bolded (p < 0.050). β: Beta coefficient; CI: Confidence interval. a) Mediation model between cardiorespiratory fitness, psychological distress, and loneliness; b) Mediation model between balance, psychological distress, and loneliness; c) Mediation model between upper limb strength, psychological distress, and loneliness; d) Mediation model between lower limb strength, psychological distress, and loneliness.

Regarding the indirect effects, a significant indirect negative effect was found for cardiorespiratory fitness (β = −3.873; 95% CI: −8.89, −0.30), balance (β = −0.270; 95% CI: −0.66, −0.03), and upper limb strength (β = −0.152; 95% CI: −0.31, −0.04) on loneliness via depression. Therefore, depression was a common significant mediator in the relationship between cardiorespiratory fitness, balance and upper limb strength with loneliness.

Overall, cardiorespiratory fitness, balance, and upper limb strength accounted respectively for 3.7%, 3.8% and 5.8% of the variance in depression, and for 2.6%, 1.0% and 1.6% of the variance in loneliness.

Discussion

This study examines the relationships between different physical fitness variables (cardiorespiratory fitness, upper limb strength, lower limb strength and balance) and loneliness in older adults and explores whether psychological distress indicators (depression, anxiety, and stress) would mediate these relationships. Our results suggest that cardiorespiratory fitness, balance, and upper limb strength have an important effect on loneliness through depression. These findings contribute to the limited current literature on the association between physical fitness and loneliness in older adults, adding new knowledge about the impact of psychological distress. They also reveal a link between balance and both, anxiety and depression. Additionally, these findings have important public health implications, revealing a possible increasing feeling of loneliness derived from a poor physical and mental health during aging.

On the one hand, our results showed that cardiorespiratory fitness, balance, and upper limb strength were all negatively linked with depression in older adults. Furthermore, balance was also associated with anxiety. These findings confirm previously reported results in the literature that highlight the importance of physical fitness for mental health in older adults. For example, some studies have demonstrated that people with higher cardiorespiratory fitness are at a lower risk of developing depressive symptoms.^38,39 Similarly, Marques et al.⁴⁰ systematic review findings suggest that muscular strength has a positive effect on reducing depression. Likewise, decreased balance significantly increases the risk of falls, leading not only to physical injuries but also to psychological consequences, such as an increase in depressive symptoms.⁴¹ Consequently, interventions aimed at improving cardiorespiratory fitness, balance and muscular strength have the potential to promote mental health and prevent depression.⁴²

On the other hand, we found that depression was strongly associated with loneliness. The association between depressive symptoms and loneliness is consistent with previous research findings^8,43 and can be understood through the lens of how depression affects interpersonal and cognitive functioning.^8,44,45 However, neither anxiety nor stress were associated with loneliness in our study, contrary to other studies that have shown that increased anxiety can elevate levels of experienced loneliness.⁴⁶ It might be due to the low outcomes of anxiety and stress in our sample.

Since there are moderate to large associations between loneliness and the three psychological distress factors, reducing the incidence of mental health diseases is essential for mitigating the global mental health burden,⁴⁷ including the cost of unwanted loneliness. Indeed, in Western countries like Spain, physical and mental illnesses associated with this unwanted loneliness entail increasing morbidity and risk of death, consequently increasing costs and care resources.⁴⁸ Interventions aimed at fostering social connections and community involvement have been shown to improve both mental and physical health outcomes in this population. Therefore, creating accessible community programs that promote social integration for those with functional limitations (e.g., the older adults) is essential for enhancing quality of life and mitigating the negative effects of isolation.⁴⁹ This is a topic that remains to be explored.

Regarding the association between physical fitness and loneliness, we found a significant indirect negative effect for cardiorespiratory fitness, balance and upper limb strength on loneliness via depression. Thus, in agreement with our hypothesis, our results imply that while physical fitness may not directly influence loneliness, the presence of depressive symptoms associated to lower condition or unfit physical function among older adults can contribute to variations in loneliness. In other words, being fitter (better cardiorespiratory fitness, balance and upper limb strength) is associated with a lower risk of depressive symptoms, which in turn are associated with less perceived loneliness. Based on our findings, improvements in fitness may underlie improvements in depressive symptoms through various biological mechanisms (autonomic regulation, cortisol balance, inflammation reduction, BDNF secretion).²³ These changes in physical and emotional state would allow older adults to develop their activities in a larger living space,⁵⁰ understood as the physical and social extension in which people carry out their daily activities and consequently, could have a positive impact on the social ties and on perceived loneliness. When you feel good about your body and your functional ability, you have less fear of falling, less fear of going out, and improved self-esteem, which results in greater social involvement.⁵¹ Maintaining/enhancing balance may play a key role through in reducing anxiety as well as depression. Accordingly, older adults who maintain a good physical fitness are indirectly less likely to loneliness because they are less likely to experience the depressive symptoms that precede loneliness.

In this manner, interventions aimed to maintaining physical fitness could be vital in preserving functionality and mental health in aging populations.^13,52 Functional problems are related to depression⁵³ and social isolation.⁵⁴ Hence, by enhancing physical fitness, older adults sustain higher levels of functionality, reducing the need for assistance with daily activities and potentially delaying the transition to assisted care. Regular exercise is the main pathway to improve physical fitness and functionality and a comprehensive biopsychosocial treatment strategy applicable to a diverse array of chronic diseases. In fact, some authors have shown how holistic interventions based on exercise and socialization combined with health education can help to improve loneliness and fitness in older adults.^55-57 In this way, enhancing physical fitness through physical exercise and physical activity is central to an integrated approach to healthy aging, addressing both physical and psychological aspects of health.^58,59 Therefore, improved physical fitness contributes positively to mental health and supports greater social engagement, which leads to better overall health.^60,61 Our results highlight the importance of integrating physical, psychological, and social interventions to prevent low levels of fitness, and high levels of psychological distress and loneliness in older adults.

The strengths of this study include an adequate sample size in terms of statistical power, and the use of objective tests to assess physical fitness in older adults. However, this study has several limitations. First, the sampling method and inclusion criteria may have created a risk of bias because the examined participants wanted to participate in a session of physical exercise and is very likely that participants with some degree of social isolation, and with moderate to high levels of psychological distress did not want to participate in the study. Moreover, a major part of the sample was female, so sex-differences could influence our results. But the reality is that more and more women take part in physical exercise activities (and cultural and social activities). Surely a gendered look at physical exercise programmes would be of interest, as we could find differences in the type of programmes that some people like more. Another potential limitation is the wide age range of participants (range: 60-88 years old) as there could exist physical and mental differences between them. Furthermore, our sample present low general levels of psychological distress and good levels of physical fitness, so future studies should investigate these associations with clinical populations. Importantly, the cross-sectional design of our analyses prevents us from inferring causal relationships as we possess only a singular snapshot of data. Eventually, a major flaw in this study is the lack of confounders in the mediation analyses. Future studies with robust longitudinal designs that incorporate significant sociodemographic and socioeconomic covariates into these analyses will need to confirm the associations found, thus contributing to the development of knowledge in this field.

In conclusion, our results support that the associations between some physical fitness variables (i.e., cardiorespiratory fitness, balance and upper limb strength) and loneliness were mediated by depression. As such, exercise interventions can help older adults in maintaining and enhancing physical fitness and mental health and live independently and social connected for longer periods, supporting healthy and successful aging. This work adds to the growing literature illustrating the predictive utility of physical fitness in social and mental health. Future studies should deep into how physical fitness might prevent loneliness in the long term. Succeeding to fill this knowledge gap can contribute to promote successful aging globally in the Decade of Healthy Ageing and thus achieve some Sustainable Development Goals (SDGs) as good health and well-being (SDG 3), gender equality (SDG 5), or reduced inequalities (SDG 10).

Footnotes

Acknowledgments

The authors would like to thank all the older adults who participated in the study, as well as general practitioners in the health care centers and The GESMED Foundation (Gestió Socio Sanitaria al Mediterrani) for their continuous support.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported by the Conselleria d'Educació, Investigació, Cultura i Esport, CIACIF/2022/368; 2023-2027; Banco Santander; Research Projects in Social Engagement 2022 from Banco Santander - Universitat Jaume I; Gestió Socio Sanitaria al Mediterrani Foundation (GESMED).

Ethical Considerations

ORCID iDs

Pablo Monteagudo

Alessandra De Maria

Sacramento Pinazo-Hernandis

Cristina Blasco-Lafarga

Data Availability Statement

The datasets generated and/or analyzed during the current study are not publicly available due to the conditions provided by the INCLIVA (May 2022 and September 2022) Human Research Ethics Committee. However, final data analysis will be made available on request.*

References

Gierveld

Tilburg

Dykstra

. New ways of theorizing and conducting research in the field of loneliness and social isolation. In: The Cambridge Handbook of Personal Relationships. doi:10.1017/9781316417867.031. Cambridge University Press; 2018:391-404.

Newmyer

Verdery

Wang

Margolis

. Population aging, demographic metabolism, and the rising tide of late middle age to older adult loneliness around the world. Popul Dev Rev. 2022;48(3):829-862. doi:10.1111/padr.12506

Richard

Rohrmann

Vandeleur

Schmid

Barth

Eichholzer

. Loneliness is adversely associated with physical and mental health and lifestyle factors: results from a Swiss national survey. PLoS One. 2017;12(7):e0181442. doi:10.1371/journal.pone.0181442

National Academies of Science Engineering and Medicine . Social isolation and loneliness in older adults: opportunities for the health care system. Published online 2020. Accessed November 8, 2024.https://books.google.com/books?hl=ca&lr=&id=SDbnDwAAQBAJ&oi=fnd&pg=PR1&dq=Social+Isolation+and+Loneliness+in+Older+Adults:+Opportunities+for+the+Health+Care+System.+Washington+(DC):+National+Academies+Press+(US).+2020+&ots=c7n5pUPNlX&sig=SA5bk3BLnA0elpaHxlZvjEyfJeM

Nummela

Seppänen

Uutela

. The effect of loneliness and change in loneliness on self-rated health (SRH): a longitudinal study among aging people. Arch Gerontol Geriatr. 2011;53(2):163-167. doi:10.1016/j.archger.2010.10.023

Paul

Fancourt

. Loneliness and risk for cardiovascular disease: mechanisms and future directions. Curr Cardiol Rep. 2021;23(6):68. doi:10.1007/s11886-021-01495-2

Barakat

Elattar

Zaki

. Depression, anxiety and loneliness among elderly living in geriatric homes. 2019;7(4):400-411. doi:10.12691/ajnr-7-4-1

Hsueh

Chen

Hsiao

Lin

. A longitudinal, cross-lagged panel analysis of loneliness and depression among community-based older adults. J Elder Abuse Negl. 2019;31(4-5):281-293. doi:10.1080/08946566.2019.1660936

Domènech-Abella

Mundó

Haro

Rubio-Valera

. Anxiety, depression, loneliness and social network in the elderly: longitudinal associations from the Irish longitudinal study on ageing (TILDA). J Affect Disord. 2019;246:82-88. doi:10.1016/j.jad.2018.12.043

10.

Laustsen

Christiansen

Maindal

Plana-Ripoll

Lasgaard

. The longitudinal relation between loneliness and perceived stress: a structural equation modelling analysis of 10,159 individuals. Scand J Publ Health. 2024;52(4):410-418. doi:10.1177/14034948231151716

11.

Musich

Wang

Schaeffer

Kraemer

Wicker

Yeh

. The association of physical activity with loneliness, social isolation, and selected psychological protective factors among older adults. Geriatr Nurs. 2022;47:87-94. doi:10.1016/j.gerinurse.2022.07.006

12.

Gyasi

Phillips

Asante

Boateng

. Physical activity and predictors of loneliness in community-dwelling older adults: the role of social connectedness. Geriatr Nurs. 2021;42(2):592-598. doi:10.1016/j.gerinurse.2020.11.004

13.

Izquierdo

Merchant

Morley

, et al. International exercise recommendations in older adults (ICFSR): Expert consensus guidelines. J Nutr Health Aging. 2021;25(7):824-853. doi:10.1007/S12603-021-1665-8

14.

Singh

Olds

Curtis

, et al. Effectiveness of physical activity interventions for improving depression, anxiety and distress: an overview of systematic reviews. Br J Sports Med. 2023;57(18):1203-1209. doi:10.1136/bjsports-2022-106195

15.

Magalhães

Hetherington-Rauth

Rosa

, et al. Functional fitness trends among older adults in Portugal between 2008 and 2018: keeping up with a healthy aging process. J Sci Med Sport. 2023;26(11):622-627. doi:10.1016/j.jsams.2023.09.002

16.

Rikli

Jones

. Development and validation of a functional fitness test for community-residing older adults. J Aging Phys Activ. 1999;7(2):129-161. doi:10.1123/japa.7.2.129

17.

Pedrero-Chamizo

Gómez-Cabello

Mélendez

, et al. Higher levels of physical fitness are associated with a reduced risk of suffering sarcopenic obesity and better perceived health among the elderly. The EXERNET multi-center study. J Nutr Health Aging. 2015;19(2):211-217. doi:10.1007/s12603-014-0530-4

18.

Furtado

Patrício

Loureiro

Teixeira

Ferreira

. Physical fitness and frailty syndrome in institutionalized older women. Percept Mot Skills. 2017;124(4):754-776. doi:10.1177/0031512517709915

19.

Vingeliene

Hiyoshi

Lentjes

Fall

Montgomery

. Ageing accounts for much of the association between decreasing grip strength and subsequent loneliness: the English longitudinal study of ageing. J Epidemiol Community Health. 1978;77(3):175-181. doi:10.1136/jech-2021-218635

20.

Encarnação

Vaz

Fortunato

Forte

Vaz

Monteiro

. Aerobic fitness as an important moderator risk factor for loneliness in physically trained older people: an explanatory case study using machine learning. Life. 2023;13(6):1374. doi:10.3390/life13061374

21.

Pedro-Costa

Hiney

Sampaio

Guimarães

Bohn

Marques-Aleixo

. Physical activity and physical fitness according to loneliness levels in adults 50+. Rev Bras Ativ Fis Saude. 2022;27:1-7. doi:10.12820/rbafs.27e0276

22.

Navarra

Tabacchi

Scardina

, et al. Functional fitness, lifestyle and demographic factors as predictors of perceived physical and mental health in older adults: a structural equation model. PLoS One. 2023;18(9):e0290258. doi:10.1371/journal.pone.0290258

23.

Kandola

Ashdown-Franks

Stubbs

Osborn

DPJ

Hayes

. The association between cardiorespiratory fitness and the incidence of common mental health disorders: a systematic review and meta-analysis. J Affect Disord. 2019;257:748-757. doi:10.1016/j.jad.2019.07.088

24.

Zasadzka

Pieczyńska

Trzmiel

Kleka

Pawlaczyk

. Correlation between handgrip strength and depression in older adults—A systematic review and a meta-analysis. Int J Environ Res Publ Health. 2021;18(9):4823. doi:10.3390/ijerph18094823

25.

Bao

Chao

Sheng

Cai

Zhang

Chen

. Longitudinal association between muscle strength and depression in middle-aged and older adults: a 7-year prospective cohort study in China. J Affect Disord. 2022;301:81-86. doi:10.1016/j.jad.2022.01.036

26.

Jeon

Cynn

. Comparison of elderly fallers and elderly non-fallers: balancing ability, depression, and quality of life. Physical Therapy Korea. 2014;21(3):45-54. doi:10.12674/ptk.2014.21.3.045

27.

Lee

. A study of the relationship between depression symptom and physical performance in elderly women. J Exerc Rehabil. 2015;11(6):367-371. doi:10.12965/jer.150257

28.

Folstein

McHugh

. “Mini-mental state”: a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975;12(3):189-198. https://www.academia.edu/download/48794085/0022-3956_2875_2990026-620160913-28497-y2c5d5.pdf

29.

Atkinson

Reilly

. Circadian variation in sports performance. Sports Med. 1996;21(4):292-312. doi:10.2165/00007256-199621040-00005

30.

Casillas

Hannequin

Besson

, et al. Walking tests during the exercise training: specific use for the cardiac rehabilitation. Ann Phys Rehabil Med. 2013;56(7-8):561-575. doi:10.1016/j.rehab.2013.09.003

31.

O’Hoski

Sibley

Brooks

Beauchamp

. Construct validity of the BESTest, mini-BESTest and briefBESTest in adults aged 50 years and older. Gait Posture. 2015;42(3):301-305. doi:10.1016/j.gaitpost.2015.06.006

32.

Alcazar

Losa-Reyna

Rodriguez-Lopez

, et al. The sit-to-stand muscle power test: an easy, inexpensive and portable procedure to assess muscle power in older people. Exp Gerontol. 2018;112:38-43. doi:10.1016/j.exger.2018.08.006

33.

Sancho

Pinazo hernandis

Donio bellegarde

Tomás

. Validation of the university of California, Los Angeles loneliness scale (version 3) in Spanish older population: an application of exploratory structural equation modelling. Aust Psychol. 2020;55(3):283-292. doi:10.1111/ap.12428

34.

Ruiz

García-Martín

Suárez-Falcón

Odriozoloa-González

. The hierarchical factor structure of the Spanish version of depression anxiety and stress scale -21. Int J Psychol Psychol Ther. 2017;17(1):97-105. https://www.redalyc.org/articulo.oa?id=56049624007. Accessed December 21, 2023.

35.

Hayes

. Introduction to Mediation, Moderation, and Conditional Process Analysis: A Regression-based Approach. 2nd ed. The Guilford Press; 2017. Accessed December 21, 2023.https://books.google.com/books?hl=ca&lr=&id=6uk7DwAAQBAJ&oi=fnd&pg=PP1&dq=+Introduction+to+Mediation,+Moderation,+and+Conditional+Process+Analysis:+A+Regression-Based+Approach%3B+Guilford+Publications:+New+York,+N&ots=Y-M7nWWvhH&sig=7rwyWNWJsvL5Sl_D9iIbxMh49eE

36.

Moshagen

Erdfelder

. A new strategy for testing structural equation models. Struct Equ Model. 2016;23(1):54-60. doi:10.1080/10705511.2014.950896

37.

Hayes

. Beyond baron and kenny: statistical mediation analysis in the new millennium. Commun Monogr. 2009;76(4):408-420. doi:10.1080/03637750903310360

38.

Monteiro-Junior

Oliveira

Leão

Baldo

de Paula

Laks

. Poor physical fitness is associated with impaired memory, executive function, and depression in institutionalized older adults: a cross-sectional study. Br J Psychiatry. 2022;44(1):41-45. doi:10.1590/1516-4446-2020-1614

39.

Gianfredi

Koster

Eussen

SJPM

, et al. The association between cardio-respiratory fitness and incident depression: the maastricht study. J Affect Disord. 2021;279:484-490. doi:10.1016/j.jad.2020.09.090

40.

Marques

Gomez-Baya

Peralta

, et al. The effect of muscular strength on depression symptoms in adults: a systematic review and meta-analysis. Int J Environ Res Publ Health. 2020;17(16):5674. doi:10.3390/ijerph17165674

41.

Kamińska

Brodowski

Karakiewicz

. Fall risk factors in community-dwelling elderly depending on their physical function, cognitive status and symptoms of depression. Int J Environ Res Publ Health. 2015;12(4):3406-3416. doi:10.3390/ijerph120403406

42.

Qiangqiang

Yongzhao

Jianghua

Xing

. The effect of different exercise on physical fitness, cognition, and mental health in healthy older adults. Heliyon. 2024;10(16):e36510.

43.

Ward

Briggs

McGarrigle

De Looze

O’Halloran

Kenny

. The bi‐directional association between loneliness and depression among older adults from before to during the COVID‐19 pandemic. Int J Geriatr Psychiatr. 2023;38(1):e5856. doi:10.1002/gps.5856

44.

McHugh Power

Hannigan

Hyland

Brennan

Kee

Lawlor

. Depressive symptoms predict increased social and emotional loneliness in older adults. Aging Ment Health. 2020;24(1):110-118. doi:10.1080/13607863.2018.1517728

45.

Muhammad

Meher

. Association of late-life depression with cognitive impairment: evidence from a cross-sectional study among older adults in India. BMC Geriatr. 2021;21(1):364. doi:10.1186/s12877-021-02314-7

46.

Van Bogart

Scott

Harrington

Felt

Sliwinski

Graham-Engeland

. Examining the bidirectional nature of loneliness and anxiety among older adults in daily life. J Gerontol B Psychol Sci Soc Sci. 2023;78(10):1676-1685. doi:10.1093/geronb/gbad105

47.

Patel

Saxena

Lund

, et al. The lancet commission on global mental health and sustainable development. Lancet. 2018;392(10157):1553-1598. doi:10.1016/S0140-6736(18)31612-X

48.

Casal

Rodríguez-Miguez

Rivera

. The societal cost of ‘unwanted’ loneliness in Spain. Eur J Health Econ. doi:10.1007/s10198-024-01724-9. Published online September 28 2024.

49.

Haldane

Chuah

FLH

Srivastava

, et al. Community participation in health services development, implementation, and evaluation: a systematic review of empowerment, health, community, and process outcomes. PLoS One. 2019;14(5):e021611249.

50.

Moored

Qiao

Rosso

, et al. Dual roles of cardiorespiratory fitness and fatigability in the life-space mobility of older adults: the study of muscle, mobility and aging (SOMMA). J Gerontol A Biol Sci Med Sci. 2023;78(8):1392-1401. doi:10.1093/gerona/glad037

51.

Blasco

. Exercise/Physical activity programmes to combat a sedentary lifestyle, chronicity and poor ageing. Arch Med Deporte. 2022;39(2):72-73. doi:10.18176/archmeddeporte.00075

52.

Langhammer

Bergland

Rydwik

. The importance of physical activity exercise among older people. BioMed Res Int. 2018;2018:1-3. doi:10.1155/2018/7856823

53.

Burton

O’Connell

Morgan

. Cognitive and neuropsychiatric correlates of functional impairment across the continuum of no cognitive impairment to dementia. Arch Clin Neuropsychol. 2018;33(7):795-807. doi:10.1093/arclin/acx112

54.

Pollak

Verghese

Blumen

. Loneliness and functional decline in aging: a systematic review. Res Gerontol Nurs. 2023;16(4):202-212. doi:10.3928/19404921-20230503-02

55.

Jones

Siever

Knuff

, et al. Walk, talk and listen: a pilot randomised controlled trial targeting functional fitness and loneliness in older adults with hearing loss. BMJ Open. 2019;9(4):e026169. doi:10.1136/bmjopen-2018-026169

56.

Mays

Kim

Rosales

Rosen

. The leveraging exercise to age in place (LEAP) study: engaging older adults in community-based exercise classes to impact loneliness and social isolation. Am J Geriatr Psychiatr. 2021;29(8):777-788. doi:10.1016/j.jagp.2020.10.006

57.

Shvedko

Thompson

Greig

Whittaker

. Physical activity intervention for loneliness (PAIL) in community-dwelling older adults: a randomised feasibility study. Pilot Feasibility Stud. 2020;6(1):73. doi:10.1186/s40814-020-00587-0

58.

Gopinath

Kifley

Flood

Mitchell

. Physical activity as a determinant of successful aging over ten years. Sci Rep. 2018;8(1):10522. doi:10.1038/s41598-018-28526-3

59.

Izquierdo

Fiatarone Singh

. Promoting resilience in the face of ageing and disease: the central role of exercise and physical activity. Ageing Res Rev. 2023;88:101940. doi:10.1016/j.arr.2023.101940

60.

Monteagudo

Roldán

Cordellat

Gómez-Cabrera

Blasco-Lafarga

. Continuous compared to accumulated walking-training on physical function and health-related quality of life in sedentary older persons. Int J Environ Res Publ Health. 2020;17(17):6060. doi:10.3390/ijerph17176060

61.

Monteagudo

Cordellat

Roldán

Gómez-Cabrera

Pesce

Blasco-Lafarga

. Exploring potential benefits of accumulated multicomponent-training in non-active older adults: from physical fitness to mental health. Int J Environ Res Publ Health. 2021;18(18):9645. doi:10.3390/ijerph18189645

The Hidden Connection: Psychological Distress as a Mediator Between Physical Fitness and Loneliness in Older Adults

Abstract

Keywords

Introduction

Methods

Data Source and Study Population

Independent Variables

Physical Fitness was Assessed Through the Following Tests

Dependent Variables

Mediation Variables

Other Variables

Statistical Analysis

Results

Discussion

Footnotes

Acknowledgments

Declaration of conflicting interests

Funding

Ethical Considerations

ORCID iDs

Data Availability Statement

References