Association of Psychological Resilience With Health-Related Quality of Life in Patients Undergoing Hip Fracture Surgery

Abstract

Health-related quality of life (HRQOL) represents a central outcome following hip fracture surgery. This study examined whether psychological resilience and other factors predict HRQOL. In this prospective longitudinal study, patients ≥60 years undergoing hip fracture surgery in southern Taiwan were consecutively recruited. HRQOL was measured by the 36-item Short Form Health Survey (SF-36) and psychological resilience by the 10-item Connor–Davidson Resilience Scale (CD-RISC-10). Both tools were administered at admission prefracture (at admission, based on recall), and at 6 and 12 weeks postoperatively. Changes and predictors of HRQOL within 12 weeks were analyzed using generalized estimating equations. Generalized estimating equations were used to analyze changes in these and predictors of HRQOL within 12 weeks after surgery. Among 50 participants (mean age 72.1 ± 9.6 years; 58% female), psychological resilience (CD-RISC-10) showed no significant changes across baseline, 6 weeks, and 12 weeks postoperatively, whereas HRQOL (SF-36 total, physical, and mental health domains) declined at 6 weeks but returned to baseline by 12 weeks (SF-36: b = −9.19, P < .001; physical health domain: b = −5.29, P < .001; mental health domain: b = −3.90, P = .001). Higher prefracture CD-RISC-10 scores significantly predicted better SF-36 total, physical, and mental health domains (all P < .001), whereas a hospital stay ≥8 days was associated with lower SF-36 and its mental health domain. In conclusion, psychological resilience supports postoperative HRQOL, underscoring its relevance as a perioperative care target. Larger, long-term studies are warranted to confirm these effects and elucidate their sustained impact.

Keywords

health outcome SF-36 mental health physical health psychological resilience

Introduction

As the global population ages, the number of older adults with hip fractures is steadily increasing, posing a substantial public health challenge worldwide. Hip fractures have a profound impact on both physical and mental functioning in older adults, often resulting in diminished quality of life and even mortality.^1–3 Surgery and postoperative rehabilitation remain the mainstay of treatment for such patients.^4,5 Taiwan, an East Asian country with a population of approximately 23 million, faces a similar burden. Epidemiological data indicate that between 1996 and 2010, the overall incidence of hip fractures ranged from 390.0 to 472.1 cases per 100 000 person-years,⁶ and most patients required surgical intervention. Thus, hip fracture care in Taiwan warrants close clinical and public health attention.

Health-related quality of life (HRQOL) has been recognized as a key health outcome in older adults with hip fractures.^2,7,8 To promote recovery, healthcare providers strive to identify factors that can enhance HRQOL following surgery. Prior studies have reported that poor prefracture physical or psychosocial health, comorbidities, female sex, longer hospital stays, and specific surgical procedures are associated with poorer HRQOL.^2,8 Beyond these clinical and demographic determinants, psychological resilience has emerged in recent decades as a promising construct relevant to recovery. Psychological resilience is generally defined as the capacity to adapt to or recover from adversity, enabling positive outcomes despite challenging circumstances. It is regarded as an individual's inner strength and set of psychological resources that facilitate adaptation, resistance to stress, accelerated healing, and the maintenance of functioning in adversity.^9–11 Initially developed in psychology and psychiatry, this concept has increasingly been applied in healthcare contexts, including internal medicine and surgical care, such as orthopedics.^3,12,13

Growing evidence suggests that psychological resilience may influence outcomes in older adults undergoing lower limb or hip surgery. For example, a cross-sectional study of 103 patients after primary total hip arthroplasty found that resilience, measured using the 25-item Connor–Davidson Resilience Scale (CD-RISC-25), predicted better physical function using the Western Ontario and McMaster Universities score.¹⁴ Another multicenter study analyzing 1360 adults aged ≥50 years who underwent hip fracture surgery in the United States and Canada demonstrated that greater resilience (measured by the Brief Resilience Scale) was associated with lower odds of death or new walking disability by day 60 among patients without complications.³ Similarly, a study of 339 older adults with hip fractures reported that resilience correlated with better self-rated health in both sexes and was explicitly linked to postoperative physical activity in men.¹⁵ Nevertheless, psychological resilience was not the primary focus in these studies, and their cross-sectional designs limit causal inference. Furthermore, a smaller rehabilitation study of 29 geriatric patients found no association between resilience (CD-RISC-25) and functional independence.¹⁶

Taken together, although psychological resilience is increasingly recognized as important for physical and mental well-being, its specific impact on HRQOL after hip fracture surgery remains unclear. Therefore, the aim of this study was to evaluate postoperative HRQOL in older adults with hip fractures and to examine the influence of psychological resilience and selected personal characteristics on HRQOL.

Methods

Study Design and Setting

This was a prospective, repeated-measures observational study conducted at Zuoying Armed Forces General Hospital, a regional medical center in southern Taiwan. Taiwan, an island in East Asia located off the southeastern coast of China and bordered by Japan to the northeast and the Philippines to the south, operates under a universal National Health Insurance program that provides coverage for more than 99% of the population, thereby ensuring broad access to both inpatient and outpatient care.

Within this system, regional hospitals serve as intermediate institutions between district hospitals and tertiary medical centers, providing general medical services as well as referral care. Zuoying Armed Forces General Hospital is a comprehensive institution with approximately 654 inpatient beds, offering internal medicine, general surgery, obstetrics and gynecology, pediatrics, emergency services, inpatient care, and multiple specialized outpatient clinics. The hospital performs roughly 100 hip fracture surgeries annually and serves both military personnel and the civilian population.

Participants and Procedures

Participants were consecutively enrolled between January and July 2021 using a consecutive sampling approach to minimize selection bias and ensure representativeness of the target population. Inclusion criteria were: (a) age ≥60 years; (b) diagnosis of hip fracture and scheduled for orthopedic surgery; (c) provision of written informed consent; and (d) ability to understand and read Chinese. Exclusion criteria included cognitive or hearing impairment, psychiatric disorder, or other severe comorbidities that could preclude data collection. All eligible patients admitted to the general surgery ward were approached individually and invited to participate. During face-to-face interviews, the study purpose, procedures, potential risks, and benefits were explained in detail, and written informed consent was obtained after confirming participants’ full understanding.

Sample Size Calculation

The sample size was calculated using generalized estimating equations (GEEs) with 3 repeated-measurement occasions, a 2-sided α of .05, and 80% power. Based on the 36-item Short Form Health Survey (SF-36) (SD ≈ 10), we hypothesized that a 1-SD increase in resilience would correspond to an improvement of approximately 3.5 points, which is consistent with the commonly cited threshold of 3 to 4 points for a clinically meaningful change in SF-36 scores. At the planning stage, the within-subject correlation coefficient (ρ) was expected to be approximately 0.7. Under these assumptions, the standard deviation of the difference was estimated as 10√2(1 − 0.7) ≈ 7.75, and the required sample size was calculated as [(1.96 + 0.84) × 7.75/3.5]² ≈ 39 to 42 participants. Considering a potential attrition rate of 10% to 20%, the final target sample size was determined to be 46 to 50 participants.

Baseline data (prefracture status, based on recall) were collected at enrollment, and postoperative follow-up assessments were conducted at 6 and 12 weeks during scheduled outpatient visits. All participants completed the 3 assessments, yielding a 100% follow-up rate. In total, 50 participants were enrolled. The study was approved by the hospital's institutional review committee and conducted in accordance with the Declaration of Helsinki.

Health-Related Quality of Life

In terms of health outcomes, the Taiwanese version of the SF-36^17,18 was used to measure HRQOL. The SF-36 was originally designed by Ware and Sherbourne¹⁹ as a multifaceted HRQOL questionnaire. It comprises 36 closed-ended questions in 8 subscales, respectively concerning physical functioning (PF), social functioning (SF), role limitations due to physical problems (RP), role limitations due to emotional problems (RE), mental health (MH), vitality (VT), bodily pain (BP), and general health perception (GH). The scoring method of the SF-36 scale is based on the standard coding and score transformation procedures provided in the SF-36 Health Survey Manual and Interpretation Guide.²⁰ Further, the PF, RP, BP, and GH subscales can be joined together to form the physical component summary (PCS). The VT, SF, RE, and MH subscales jointly constitute the mental component summary (MCS). A higher score indicates a better quality of life in the corresponding dimension. Prior to implementation, formal authorization was obtained from the original author for use of the SF-36 in this study.

Psychological Resilience

As an independent variable of interest, psychological resilience was assessed using the Chinese version of the 10-item Connor–Davidson Resilience Scale (CD-RISC-10).^21,22 The CD-RISC-10 comprises 10 items categorized into flexibility (2 items), sense of self-efficacy (3 items), ability to regulate emotion (1 item), optimism (3 items), and cognitive focus/maintaining attention under stress (1 item). It is used to evaluate respondents’ self-perceived ability to overcome or adapt to challenges in the past month. Each item is rated on a 5-point scale, with a score of 0 indicating “never,” 1 indicating “rarely,” 2 indicating “sometimes,” 3 indicating “often,” and 4 indicating “almost always.” The total score ranges from 0 to 40, with higher scores indicating higher psychological resilience.²¹ The psychometric properties of the CD-RISC-10 have been reported as excellent in a previous study.²² Cronbach's alpha for this scale was .92 in the present study, indicating good internal consistency.

Personal Baseline Characteristics

The personal characteristics included in our analyses were age, sex, the Charlson comorbidity index (CCI) score,²³ type of fracture (neck of femur, intertrochanteric, or subtrochanteric), type of surgery (internal fixation or arthroplasty), and the length of hospital stay (<8 vs ≥8 days).

Data Analysis

Categorical variables were presented as frequencies and percentages, and continuous variables as means and standard deviations. GEE, a semiparametric method that provides robust estimates of regression parameters for longitudinal data with repeated measures, was employed to examine changes in the CD-RISC-10 score as well as the SF-36 total, PCS, and MCS scores across 3 time points—prefracture (retrospectively recalled at admission), 6 weeks postoperatively, and 12 weeks postoperatively. Furthermore, GEE was employed to identify significant predictors of HRQOL and its physical and mental domains. These models were adjusted for covariates including time, sex, age, CCI, type of fracture, type of surgery, length of hospital stay, and prefracture CD-RISC-10 score. In GEE analyses, an exchangeable correlation structure was specified, assuming equal correlations among repeated measures.

Results

Participants’ Baseline Characteristics

Table 1 presents the baseline characteristics of the study participants. A total of 50 patients were included, with a mean age of 72 years (standard deviation = 9.6), and 58% were women. Femoral neck fractures were the most common type (60%). Arthroplasty was the predominant treatment (62%, n = 31), whereas 38% (n = 19) underwent internal fixation. Additionally, 36% (n = 18) had a hospital stay of ≥8 days.

Table 1.

Participants’ Characteristics (N = 50).

Variable	n	%	Mean ± SD
Sex
Men	21	42
Women	29	58
Age, years			72.12 ± 9.59
≥60, <70	23	46
≥70, <80	16	32
≥80	11	22
Charlson comorbidity index
0	32	64
≥1	18	36
Type of fracture
Neck of femur	30	60
Intertrochanteric	18	36
Subtrochanteric	2	4
Type of surgery
Open reduction internal fixation	19	38
Hemiarthroplasty	31	62
Length of hospital stay
<8 days	32	64
≥8 days	18	36

Changes in Psychological Resilience and HRQOL Across Timepoints

As shown in Table 2, the GEE analysis revealed no significant changes in psychological resilience (CD-RISC-10) across baseline, 6 weeks, and 12 weeks, postoperatively. The baseline mean score was 22.78, and neither the 6-week nor the 12-week values differed significantly from baseline. Furthermore, Figure 1 illustrates that the overlapping 95% confidence intervals (CIs) confirm the stability of psychological resilience throughout the postoperative recovery period. These findings suggest that psychological resilience remained stable and was not influenced by the postoperative recovery process.

Figure 1.

Trends in resilience (CD-RISC-10) over time. Estimated marginal means (±SE) of resilience scores at baseline (Preop), 6 weeks, and 12 weeks after surgery, based on GEE linear models. Error bars indicate standard errors of the mean.

Table 2.

Results of the GEE Linear Models for Psychological Resilience (CD-RISC-10) and Health-Related Quality of Life (SF-36 Total, PCS, and MCS) Across Three Time Points.

Dependent Variable	Predictor/Contrast	b/Mean Diff	SE	[95% CI]	P
CD-RISC-10
	Intercept (prefracture)	22.78	0.96	[20.90, 24.66]	<.001*
	6 weeks vs prefracture	−0.80	0.80	[−2.36, 0.76]	.315
	12 weeks vs prefracture	0.38	0.80	[−1.18, 1.94]	.633
SF-36
	Intercept (prefracture)	96.17	1.99	[92.26, 100.07]	<.001*
	6 weeks vs prefracture	−9.19	2.11	[−13.33, −5.06]	<.001*
	12 weeks vs prefracture	0.43	2.11	[−3.70, 4.57]	.837
PCS
	Intercept (prefracture)	50.05	1.17	[47.76, 52.33]	<.001*
	6 weeks vs prefracture	−5.29	1.37	[−7.98, −2.61]	<.001*
	12 weeks vs prefracture	1.67	1.37	[−1.01, 4.36]	.222
MCS
	Intercept (prefracture)	46.12	1.05	[44.05, 48.19]	<.001*
	6 weeks vs prefracture p	−3.90	1.07	[−6.00, −1.80]	.001*
	12 weeks vs prefracture	−1.24	1.07	[−3.34, 0.86]	.248

Abbreviations: SF-36, 36-item Short Form Health Survey; PCS, physical component summary; MCS, mental component summary; CD-RISC-10, 10-item Connor–Davidson Resilience Scale; GEE, generalized estimating equation; CI, confidence interval.

The GEE models report regression coefficients (b), standard errors (SE), and Wald 95% CIs.

*P < .05.

With respect to HRQOL outcomes, the SF-36 total score, PCS, and MCS exhibited a similar temporal pattern. At 6 weeks, scores were significantly lower than baseline (SF-36: b = −9.19, SE = 2.11, 95% CI: [−13.33, −5.06], P < .001; PCS: b = −5.29, SE = 1.37, 95% CI: [−7.98, −2.61], P < .001; MCS: b = −3.90, SE = 1.07, 95% CI: [−6.00, −1.80], P = .001). In contrast, no significant differences from baseline were observed at 12 weeks (all P > .05). Figure 2 further illustrates this transient decline at 6 weeks, followed by recovery to baseline levels at 12 weeks. These results indicate that the decline in HRQOL was temporary and resolved by 12 weeks postoperatively.

Figure 2.

Trends in HRQOL (SF-36, PCS, and MCS) over time. Estimated marginal means (±SE) of SF-36, PCS, and MCS scores at baseline (Preop), 6 weeks, and 12 weeks after surgery, derived from GEE linear models. Error bars represent standard errors of the mean. Abbreviations: HRQOL, health-related quality of life; SF-36, 36-item Short Form Health Survey; PCS, physical component summary; MCS, mental component summary; GEE, generalized estimating equation.

Predictors of the SF-36 Total Score and Its Two Dimensions

Table 3 presents the results of the predictors for the total SF-36 score and its PCS and MCS dimensions. A higher prefracture CD-RISC-10 score was associated with a better SF-36 total score (b = 0.89, standard error [SE] = 0.17, 95% CI: [0.56, 1.21], P < .001), PCS score (b = 0.41, SE = 0.10, 95% CI: [0.21, 0.61], P < .001), and MCS score (b = 0.48, SE = 0.09, 95% CI: [0.31, 0.65], P < .001). In contrast, a longer hospital stay (≥8 days) was significantly associated with a lower overall SF-36 score (b = −5.28, SE = 2.40, 95% CI: [−9.98, −0.58], P = .028) and MCS score (b = −3.63, SE = 1.29, 95% CI: [−6.15, −1.10], P = .005). Other covariates, including sex, age, comorbidity (CCI), diagnosis, and operation type, were not significantly associated with HRQOL scores. Taken together, the findings suggest that prefracture psychological resilience serves as a protective factor for postoperative HRQOL, while a prolonged hospital stay (≥8 days) represents a risk factor for poorer HRQOL.

Table 3.

Predictors of Health-Related Quality of Life (HRQOL: QOL, PCS, and MCS) by GEE With Adjusted for All Covariates (N = 50).

	SF-36 Total (HRQOL)		SF-36 PCS (physical domain)		SF-36 MCS (mental domain)
Predictor	b (SE)[95% CI]	P	b (SE)[95% CI]	P	b (SE)[95% CI]	P
Intercept	94.92 (13.44) [68.58, 121.26]	<.001	51.46 (8.21) [35.37, 67.55]	<.001	43.46 (7.20) [29.35, 57.57]	<.001*
Time (ref = prefracture)	0
6 weeks after surgery	−9.21 (2.17) [−13.46, −4.97]	<.001	−5.30 (1.41) [−8.06, −2.54]	<.001	−3.91 (1.10) [−6.07, −1.75]	<.001*
12 weeks after surgery	0.45 (2.17) [−3.79, 4.70]	.835	1.68 (1.41) [−1.08, 4.44]	.232	−1.23 (1.10) [−3.39, 0.93]	.265
Sex (ref. = men)
Women	2.46 (2.38) [−2.21, 7.13]	.302	1.17 (1.46) [−1.69, 4.02]	.423	1.29 (1.28) [−1.21, 3.80]	.311
Age (per 1-year increase)	−0.20 (0.14) [−0.47, 0.06]	.135	−0.16 (0.08) [−0.32, 0.01]	.062	−0.05 (0.07) [−0.19, 0.10]	.507
Charlson comorbidity index (ref <1)
≥1	−3.17 (2.47) [−8.02, 1.67]	.199	−1.47 (1.51) [−4.43, 1.49]	.330	−1.70 (1.33) [−4.30, 0.90]	.199
Type of fracture (ref = neck of femur)
Intertrochanteric	−4.60 (8.58) [−21.41, 12.23]	.592	−0.89 (5.24) [−11.16, 9.38]	.865	−3.70 (4.60) [−12.71, 5.32]	.421
Subtrochanteric	−8.56 (10.59) [−29.33, 12.20]	.419	−3.16 (6.47) [−15.84, 9.52]	.625	−5.40 (5.68) [−16.53, 5.73]	.342
Type of surgery (ref = ORIF)
Hemiarthroplasty	−1.12 (8.73) [−18.23, 15.99]	.898	2.23 (5.33) [−8.22, 12.68]	.675	−3.35 (4.68) [−12.52, 5.82]	.474
Length of hospital stay (<8 days, ref.)
≥8 days	−5.28 (2.40) [−9.98, −0.58]	.028	−1.65 (1.47) [−4.53, 1.22]	.259	−3.63 (1.29) [−6.15, −1.10]	.005*
Prefracture CD-RISC-10 (per 1-point increase)	0.89 (0.17) [0.56,1.21]	<.001	0.41 (0.10) [0.21, 0.61]	<.001	0.48 (0.09) [0.31, 0.65]	<.001*

Abbreviations: HRQOL, health-related quality of life; SF-36, 36-item Short Form Health Survey; PCS, physical component summary; MCS, mental component summary; CD-RISC-10, 10-item Connor–Davidson Resilience Scale; ORIF, open reduction internal fixation; GEE, generalized estimating equation; CI, confidence interval.

Regression coefficients (b), standard errors (SE), 95% Wald confidence intervals (CI), and P-values for predictors of HRQOL outcomes. Prefracture baseline was used as the reference group for time comparisons.

*P < .05.

Discussion

In this study, we examined temporal changes in HRQOL following hip fracture surgery, with particular attention to the effects of prefracture psychological resilience and baseline characteristics. The results revealed several important insights.

Regarding the trajectory of postoperative HRQOL in fracture patients, a significant decline was observed at 6 weeks, with recovery to prefracture levels by 12 weeks. This result indicates that patients generally require at least 12 weeks to regain their prefracture HRQOL, a finding consistent with a previous systematic review reporting early postoperative decline followed by gradual recovery within 2 to 6 months.⁸ These results provide healthcare providers with useful prognostic information to better counsel patients and manage expectations regarding the recovery process.

Psychological resilience was found to remain stable and emerged as an important determinant of HRQOL during the postoperative recovery period in patients undergoing hip fracture surgery. Previous literature has indicated that psychological resilience is typically conceptualized as a relatively enduring trait.^24–26 Moreover, prefracture psychological resilience has been shown to exert a protective effect on physical health outcomes over a 6-month postoperative follow-up,²⁷ as well as on psychological well-being in older adults.²⁸ The present study further corroborates the view that psychological resilience is a stable, health-promoting resource rather than merely a transient response. It may serve as an important facilitator of HRQOL in postoperative recovery after fracture surgery. Therefore, incorporating psychological resilience assessment into routine preoperative evaluations and integrating targeted interventions into perioperative care is clinically warranted. In addition, for patients with low resilience, timely interventions such as psychological counseling or coping-skills training may support postoperative recovery and thereby improve HRQOL

From a clinical perspective, psychological resilience has been shown to be positively associated with psychological constructs such as social support and active coping strategies,^11,29,30 and self-efficacy,³¹ and negatively associated with depression and anxiety.^30,32 Notably, it is often regarded as a mediating^29,33 or moderating factor³⁴ in the relationship between physical or psychological variables and HRQOL. For instance, 1 study reported that psychological resilience mediated the effects of health literacy and social support on HRQOL,²⁹ whereas another suggested that it moderates the impact of physical symptoms on HRQOL.³⁴ From a biological perspective, psychological resilience is regulated by systems such as the immune system, the hypothalamic–pituitary–adrenal axis, the autonomic nervous system, and the endocannabinoid and opioid systems. Through molecular mechanisms and factors involving neurotransmission, inflammation, oxidative stress, endocrine functions, and genetic components, these processes may also support both physical and psychological functioning, thereby enhancing HRQOL.^35–37 Although these findings suggest a link between prefracture resilience and HRQOL, the specific underlying mechanisms remain unclear and warrant further investigation.

Another finding of this study was that a longer hospital stay (≥8 days) was associated with a poorer overall HRQOL and lower MCS score than a shorter stay. This finding was congruent with those of previous studies.^2,8 A prolonged hospital stay may reflect underlying complications or a generally poor health status, which in turn can negatively impact postoperative psychological well-being. Based on this finding, healthcare providers should consider tailoring the care of patients with prolonged hospital stays due to health complications to promote both physical and psychological well-being.

Hip fractures in older adults are often followed by prolonged recovery and unfavorable outcomes. Our findings highlight the importance of psychological resilience as a modifiable factor influencing HRQOL after surgery and address an important gap in the literature. In addition, by applying GEEs to analyze repeated measures of HRQOL, this study obtained more robust estimates than traditional methods, underscoring the suitability of this analytical approach. However, several limitations should be noted. First, given the observational design, causal inferences cannot be established; therefore, the results should be interpreted with caution, and further experimental or interventional studies are warranted to determine causality. Second, the protective mechanisms through which psychological resilience influences HRQOL remain unclear, and additional research is needed to strengthen the theoretical foundation underlying this relationship. Third, though we employed GEEs, which is appropriate for small samples, enabling us to detect a significant association between psychological resilience and HRQOL, the modest sample size (N = 50) from a single hospital might have limited the generalizability of our findings. Future studies with larger and more diverse samples are warranted to validate these findings.

Conclusion

Psychological resilience contributes to postoperative recovery and HRQOL and can therefore be regarded as an important goal of perioperative care. Future studies with larger samples and longer follow-up are needed to validate these findings and clarify the long-term impact of resilience-enhancing strategies on patient outcomes.

Footnotes

Acknowledgments

The authors thank all the people who participated for their important contributions.

Declaration of Conflicting Interests

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

Ethics Approval and Informed Consent Statements

This study was approved by the ethics committee of Kaohsiung Armed Forces General Hospital (No. KAFGHIRB 109-026). All participants gave written informed consent.

Funding

The authors disclosed receipt of the financial support for the research and authorship of this article. Funding was received from Zuoying Armed Forces General Hospital, Kaohsiung, Taiwan.

ORCID iD

Aih-Fung Chiu

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