Moderating effect of IADL on the relationship between depression and loneliness in cognitive frailty people

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Few studies have focused on physical and mental health together among people with cognitive frailty, little is known about the role of daily activity in the association between depression and loneliness among elderly individuals with cognitive frailty. Objectives: To determine the direct effect of loneliness on depression among community-dwelling older adults with cognitive frailty as well as the moderating effect of daily activity. Design, setting, participants, and measurements: This cross-sectional study included 529 adults aged 65 years and older from community-dwelling population who were screened for cognitive frailty, and was conducted from July 2023 to December 2023. The participants were assessed using validation instruments for measuring main variables: Short-form Geriatric Depression Scale, loneliness questionnaire, Athens Insomnia Scale, Instrumental Activities of Daily Living (IADL), Social Support Scale, and sociodemographic characteristics. Results The IADL, depression, insomnia, and loneliness scores were lower among individuals with frailty than among individuals with prefrailty. The interaction effect of IADL* loneliness illustrated that the moderating effect of IADL on the relationship between loneliness and depression significantly differed based on the IADL score. When IADL scores were low, the impact of loneliness on depression was more significant. Conclusions The integrity of physical and social connections has a protective effect on the mental health of elderly with cognitive frailty. It is necessary to pay attention to disability and loneliness among elderly individuals. Targeted interventions for improving physical activity and social participation seem to be practical and feasible solutions to alleviate depressive symptoms. Cognitive Moderation analysis Depression IADL Loneliness Frailty Older people Figures Figure 1 Introduction Due to the rapidly ageing population worldwide, an increasing proportion of older adults will exhibit a decrease in functional status and increased risks of frailty and cognitive impairment, among other age-related conditions. Cognitive frailty (CF) is defined as the conjunction of physical frailty with cognitive impairment but not the presence of a neurological condition. CF is a potentially reversible condition and is not necessarily an intermediate stage between normal ageing and dementia( 1 ). Although individuals with CF do not have a clear clinical diagnosis, it can still present with multidimensional deficits, including depression, decreased function, loneliness, and social and physical frailty. A few studies have reported that CF is more strongly associated with adverse health outcomes, such as disability in basic activities of daily living (BADL), Instrumental Activities of Daily Living Scale (IADL), low quality of life, and death, than cognitive impairment or physical frailty alone( 2 , 3 ). On the other hand, compared with people who have already developed cognitive impairment, older adults with CF are relatively young, their physical functions are still intact, and their perceptions are normal. Therefore, they have a high demand for social participation, interpersonal communication, and a high quality of life, which we hope to help patients achieve( 4 ). The loss of physical and cognitive function may be related to the environment and can reflect the limited opportunities for older adults to participate at the community level( 5 ). An increasing number of studies have shown that elderly people with cognitive decline are vulnerable to loneliness, even if the association is bidirectional. The potential reason for this association may be lifestyle factors (e.g., living alone, deceased friends and partners, chronic illnesses) that increase the risk of negative health outcomes associated with loneliness (e.g., poor immune function, mental health risks, heart disease)( 6 , 7 ). Elderly individuals with CF often experience declines in physical function, reduced mobility, and sensory and perceptual difficulties( 8 ); furthermore, dwelling and social institutions are incapable of providing adequate facilities or municipal services as the global population ages, which has an isolating effect on individuals, as their ability to go out and engage in social activities may be compromised( 9 ). In addition to loneliness, mental health problems are commonly reported among individuals with CF. Late-life depression increases the prevalence of physical illness, reduces quality of life, causes many medical conditions, and exacerbates disability. From a clinical and public health perspective, the factors influencing depressive symptoms among older adults should be explored to facilitate the early detection of depression and improve quality of life( 10 ). Recent studies have suggested that 16%~35% of individuals with frailty also experience coexisting depression and that the prevalence of depression in older adults with frailty is as high as 46.5%( 11 ). The incidence of cognitive decline comorbid with depression among elderly individuals is high, and both factors influence each other. It has been reported that cognitive impairment occurs in 85%~94% of patients with acute depressive episodes and in 39%~44% of patients after a depressive episode has subsided. Depression among China’s elderly population is associated with the trajectory of changes in cognitive function( 12 ). As CF represents a decline in physical function, IADL, which include cooking, laundry, transport, and finance management, are likely affected among individuals with CF. Deficits in performing these self-care-related IADL are more pronounced among elderly individuals, and this disability is independently associated with depression( 13 ). A cross-sectional study of 207 Japanese Americans (aged ≥ 68 years) revealed that older adults with high levels of functional status in IADL have lower odds of depressive symptoms (OR: 0.2, 95% CI: 0.09–0.50)( 10 ). People with disabilities in complex activities and with reduced efficiency of cognitive functions, who are more dependent on others, and who have greater deficits in self-care are more likely to be depressed. Previous research has confirmed that older people with more severe functional impairment are more likely to experience depressive symptoms( 3 , 14 ). A longitudinal study from Western countries revealed that loneliness was associated with an increase in ADL difficulties. It seems that loneliness and decreased daily living ability are common risk factors for depression. However, little is known about the associations among depressive symptoms, loneliness, and IADL disabilities among community-dwelling older people with cognitive decline and physical dysfunction. Loneliness and depression are more common in elderly people with CF than in cognitively normal elderly people. Moreover, the ability to use tools among elderly people seems to be related to depression, but this relationship has not been examined in detail among individuals with cognitive decline. The relationships among the deterioration of cognitive functions, physical functions, mental functions, and independence in everyday life should be explored. Therefore, this study aimed to analyse the influence of loneliness on depressive symptoms and the moderation effect of IADL on the direction from loneliness to depression among older adults with CF. Methods Study population The study is a cross-sectional survey of frailty prevalence and relevant factors among community-dwelling elderly people that was initiated in July 2023 to December 2023. This survey finally included 529 participants, the inclusion criteria were: a) aged 65 years or above; b) be able to complete the survey with the aid from research assistants; c) not at the end stage of serious diseases; d) assigned informed consent and voluntary to participate; and e) the MoCA score<26, for those with less than 12 years education, an additional 1 point will be added to the original score, and the Clinical Dementia Rating Scale (CDR) was on 0.5 score at the same time. The Fried type score was ≥ 3. The exclusion criteria were: a) clinically diagnosed with dementia or mental health illness, b) with severe organ dysfunction and in the final stage of the disease, c) with severe hearing, vision, and language impairment or other physical conditions that hold back them to complete the investigation. According to the previous prevalence of frailty was 10%, and the formula , the minimum sample size for the cross-sectional survey would be 865 to screen people with cognitive frailty among general elderly. Measures Demographic characteristics: The general sociodemographic information were recorded, including gender, age, education level, job before retirement, living status, activity status, body mass index, chronic disease history, smoking and alcohol history, and medication usage. Frailty phenotype: Frailty was assessed and defined using a modified Fried frailty phenotype comprising five criteria: slowness, weakness, exhaustion, weight loss, and low activity( 15 ). Based on these criteria, participants received a sum score ranging from zero to five. For each of the characteristics, one point is given if the measure is positive for frailty, in the absence of any characteristic suggestive of frailty, persons are robust, whereas persons with 3–5 characteristics are considered frail. The presence of 1 or 2 characteristics indicates a prefrail condition. Short-form Geriatric Depression Scale(GDS-15): The short-form geriatric depression scale involved 15 items (GDS-15) which were extracted from the 30-item version, and high correlation index was found between the GDS full and short forms (r = 0.91, P < 0.01). The Cronbach’s alpha was 0.7( 16 )and it has been widely used to screen depression among elderly in nursing home and medical institutions. The GDS-15 score range from 0 to 15 and higher score referred to severe depression. Athens Insomnia Scale (AIS-8): The Athens Insomnia Scale contains 8 items, and the first five address the participant’s nighttime symptoms (difficulty in sleep initiation, difficulty in maintaining sleep and early morning awakening), while the last three items address the daytime impact due to any reported sleep disturbances. The respondents were required to provide a positive rating if they had experienced a sleep difficulty described in each item at least three times a week during the last month. A maximum total score of 24, indicating the most severe symptoms of insomnia, was possible, while a cut-off point of ≥ 6 represented a minimum criterion for the confirmation of insomnia symptoms( 17 ). Instrumental Activity of Daily Living (IADL): The IADL scale was used to evaluate instrumental living activities consisting of 8 questions. The response spectrum is based on a 5-Likert, in the area of using the telephone (3 items), shopping(3 items), food preparation(3 items), home activities(4 items), washing clothes(2 items), transportation (4 items), drug administration (2 items), and financial management (2 items). The total score ranged between 0 to 23, and higher score indicates the greater of a person’s abilities. The Cronbach’s alpha was 0.75( 18 ). Social Support Scale(SSRS): The scale was developed to assess how much support respondents received from participants’ family, friends, and social contexts, and SSRS consists of 10 items with a total score of 60. The level of social support that individuals expect and receive can be understood through this scale. Higher score of SSRS indicates better level of social support. The Cronbach’s alpha for the present study was 0.788( 19 ). Lubben Social network scale: We used Lubben Social network scale to measure individual’s perceived of social engagement including family and friends by self-report. The scale consists of 12 items with response to each item rating from 0 (less social engagement) to 5 (more social engagement). Higher total score indicating more social engagement. The Cronbach alpha for the LSNS is 0.7( 20 ). Loneliness assessment: The loneliness was evaluated by the question “How often do you feel alone?” The response was a Likert-5 option, 0 means “not at all”, where 4 refers to “always”. Higer scores indicates higher level of loneliness. Statistical analysis First, the demographic characteristics data was analyzed by number and percentage, the other data collected was analyzed using a descriptive analysis of means and standard deviation for each variable to be analyzed. We divided participants into 2 sub-groups on the basis of frailty type (pre-frailty vs. frailty), and R×C χ² Test was used to compare the difference between two sub-groups. Second, the spearman correlation analysis was conducted among the variables which are sleep, loneliness, IADL, social net, social support, age, and depression. The linear regression models reported in the study considered depression as the dependent variable, three models were calculated. The first model, sleep, loneliness and social network were selected enter the model. In the second model included the moderation variable of IADL, and the third model, the moderation effect of IADL and loneliness was analyzed included in the model. The statistical method of the third model included moderation analysis using the PROC REG step in SAS 9.4. For the moderation effect, variables were centered to the mean and interactions were created by calculating the product of loneliness and IADL. The liner regression analysis incorporated two variables and the moderation variable. To determine significant interactions, a simple slope analysis was performed at low (− 1 SD), and high (+ 1 SD) levels of the moderator45. Hypothesis was tested based on confidence intervals, effect size and significant interactions ( P < 0.05). Ethical consideration This research was reviewed and approved by the ethics committee of the Peking Union Medical College Hospital on 8 October, 2022 (project: National High Level Hospital Clinical Research Funding, approval number: 2022-PUMCH-B-130) Results Participant characteristics Total 529 elderly considered as cognitive frailty involved in the final statistical analysis. Descriptive statistics of demographics, sleep, depression level, IADL, and loneliness are presented in Table 1 , and the difference of comparing those variables based on frailty type were also conducted. The age, IADL scores, job types, and education level were significantly difference between subtypes of frailty level. When compared the characteristics of considered frailty (N = 146) with pre-frail, the considered frailty elderly were older than pre-frail (84.18 vs. 80.27, P < .001), the level of dependable indicated by IADL scores was worse than pre-frail (5.71 vs.7.01, P < .001), major participant with bachelors degree were considered as pre-frail (P < .001). The levels of depress and insomnia were presented worse among considered frailty, most participants among pre-frail showed a light degree of loneliness and a stronger social net. Table 1 Demographic characteristics of frailty elderly (N = 529) Pre-frail Considered-frailty Variable Overall, N = 529 N = 146 (28%) N = 383 (72%) P -value Age 81.34 ± 6.25 84.18 ± 5.32 80.27 ± 6.24 < .001 Gender .169 Female 321 (60.68%) 96 (29.91%) 225 (70.01%) Male 208 (39.32%) 50 (24.03%) 158 (75.97%) BMI .519 <18.5 24 (4.51%) 7 (29.17%) 17 (70.83%) 18.5 ~ 25 321 (60.68%) 87 (27.10%) 234 (72.90%) ≥ 25 184 (34.78%) 50 (27.17%) 134 (72.83%) Smoking or drinking .463 No 504 (95.27%) 137 (27.18%) 367 (72.82%) Yes 25 (4.73%) 9 (36.0%) 16 (64.0%) Multi-tablet .579 No 244 (46.12%) 64 (26.23%) 180 (73.77%) Yes 285 (53.88%) 82 (28.77%) 203 (71.23%) Living status < .001 Living alone 75 (14.18%) 19 (25.33%) 56 (74.64%) Living with domestic helper(s) 40 (7.56%) 16 (40%) 24 (60%) Living with family 415 (78.45%) 112 (26.98%) 303 (73.02%) Occupation before retirement < .001 Administrative personnel 179 (33.65%) 33 (18.44%) 145 (81.56%) Worker 269 (50.85%) 66 (24.54%) 203 (75.46%) farmer 69 (13.04%) 41 (59.42%) 28 (40.58%) Other 13 (2.46%) 6 (46.15%) 7 (53.85%) Education < .001 Primary school 44(8.32%) 28 (63.64%) 16 (36.36%) Junior high school 87 (16.45%) 32 (36.78%) 55 (63.22%) Senior high school 216 (40.83%) 53 (24.54%) 163 (75.46%) Bachelor or higher 182 (34.40%) 33 (18.13%) 149 (81.87%) Depression 2.76 ± 1.50 3.00 ± 1.89 2.67 ± 1.30 .209 IADL 6.65 ± 1.91 5.71 ± 2.19 7.01 ± 1.67 < .001 Sleep 4 ± 1.94 4.47 ± 1.32 3.80 ± 1.74 .154 Alone .118 0–1 (scores) 355 (67.11%) 86 (24.22%) 259 (75.78%) 2–4 (scores) 174 (36.89%) 50 (28.74%) 124 (71.26%) Preliminary analyses The Table 2 shows the results of the Spearman correlation analysis. All the key variables were significantly correlated with one another, and there were moderate-strength associations observed between IADT, age, and depression. The correlations between sleep, depression, loneliness, and age were weak. Table 2 The correlation analysis of variables (N = 529) Sleep Depress Social Support Social net IADL Loneliness Age Sleep 1 0.113 0.054 -0.067 -0.056 -0.001 0.009 0.20 0.1219 0.1926 0.998 Depress 0.113 * 1 0.058 -0.073 -0.253 0.101 0.009 0.1804 0.0912 < .0001 0.020 Social Support 0.054 0.058 1 -0.01441 0.01031 -0.059 0.209 0.180 0.740 0.812 0.172 Social net -0.067 -0.073 -0.014 1 -0.035 0.000 0.121 0.091 0.749 0.412 0.995 IADL -0.056 -0.253 * 0.010 -0.035 1 -0.087 0.192 < .0001 0.812 0.412 0.043 Loneliness -0.000 0.101 * -0.059 0.000 -0.087 * 1 0.998 0.020 0.172 0.995 0.043 Age 0.054 -0.031 -0.026 0.004 -0.231 * 0.0191 1 0.2144 0.482 0.5424 0.915 < 0.001 0.802 * P < .05 Moderation analyses The level of IADL was found to moderate the relationship between loneliness and depression (Table 3 ). The three models presented in Table 3 indicate the regression coefficients of the variables that were considered in the hypotheses of this study. In model 1, only the control and independent variables were considered, and both variables were significant. In the case of sleep, the regression coefficient was β = 0.04, P < 001; for social networks, the regression coefficient was β=-0.02, P = 0.03; and for loneliness, the regression coefficient was β=-0.02, P = .03. In model 2, we added the moderation variable IADL into the regression analysis. The regression coefficient for sleep was β = 0.036, P = .02; for social networks, the regression coefficient was β=-0.02, P=-0.013, P < .01; for loneliness, the regression coefficient was β = 0.145, P = .02; and for the moderator IADL, the regression coefficient was β=-0.191, P < .01. In model 3, which was based on Hayes’ linear regression analysis, we added the interaction variable of IADL * loneliness, which yielded a significant coefficient of β=-0.116, P < .01. Most of the variables included in the model were significant, except for social network (β=-0.024, P = 0.19). The regression coefficient for the interaction of IADL* loneliness was β=-0.116, P < .01, which indicated that the effect of the moderator IADL on the relationship between loneliness and depression significantly differed based on the IADLT. Table 3 Moderation graph of the moderation for the effect of IADL in the relationship between loneliness and depress (N = 529) Model 1 Model 2 Model 3 β t LLCI ULCI β t LLCI ULCI β t LLCI ULCI Sleep 0.04 * 2.51 0.01 0.05 0.036 * 2.25 0.028 0.078 0.033 * 2.08 0.022 0.068 Social network -0.02 * -1.84 -0.12 -0.016 -0.013 -1.81 -0.126 0.590 -0.024 -2.02 -0.039 0.489 Loneliness 0.19 * 2.35 0.06 0.25 0.145 * 1.97 0.026 0.358 0.922 * 2.61 0.095 0.932 IADL -0.191 * -5.79 -0.236 -0.022 -0.086 * -2.26 -0.192 -0.032 IADL*Loneliness -0.116 * -2.09 -0.756 -0.056 R2 0.11 R2 0.15 R2 0.18 * P < .05 Furthermore, Fig. 1 shows that when the IADL is high, the impact of loneliness on depression is weaker. Conversely, when the IADL is low, the impact of loneliness on depression is more significant. Discussion This study aimed to examine the moderating effect of IADL on the relationship between loneliness and depression. On the basis of previous reports on the psychological, physiological, and social factors of frail populations, further exploration of regulatory factors has provided insights beyond the flat description results, and studies have examined factors associated with the characteristics of frail populations. This study further highlights the integration and mutual influence of the weakened population from multiple perspectives – including social, physiological, and psychological perspectives – thus suggesting that there is a synergistic effect of physical health and social participation on the mental health of elderly individuals. The aim of this study was to highlight regulatory factors that may improve the mental health of elderly people with prefrailty or frailty, thus promoting their successful ageing. The results reported in the current study contribute to the literature by examining the characteristics and heterogeneity between different stages of frailty in people. Furthermore, we found that the path from loneliness to depression is mediated by IADL. The average age of our participants was over 80 years, which inevitably led to a high incidence of geriatric syndrome, as most of the elderly reported insomnia, depressive symptoms, and worse physical ability than did those reported in previous studies( 21 , 22 ). Severe physical ability and movement barriers somewhat hinder elderly people from participating in social interactions, and living separate from family members led to loneliness and depression. Previous studies reported that frailty was associated with increased feelings of loneliness, social isolation, and depression, and prefrail patients were more likely to report neuropsychiatric disorders, such as sleep disorders. Prospective findings have shown a link between loneliness and a decline in gait speed or mobility and increased difficulty with ADLs( 23 ). These findings are consistent with our results( 24 ), and further exploration of potential reasons may be due to social isolation. A study conducted among older adults reported high prevalence rates of loneliness and social isolation, which were driven by the loss of social partners, the reduction in social contact, and physical limitations( 24 ). A person’s health status and loneliness are interrelated, as loneliness can lead to pain, depression, and mental health problems( 25 ). Older people who reported greater feelings of loneliness were eight times more likely to experience worse mental health than those who experienced less loneliness. The older adults in our study may have experienced a loss of relationship or interest. Moreover, evidence has shown that the absence of an intimate relationship results in a greater level of loneliness( 26 ). Some informal social support, such as group integrated intervention programs, could not only improve their social interactions but also strengthen their cognitive and physical capabilities( 27 ). Active engagement in social and cognitive activities was found to be negatively related to both loneliness and hopelessness in older Chinese people( 28 ). The novelty of this study lies in the finding that IADL is associated not only with depression and loneliness but also with the balance between the two mental health conditions. When IADL is involved in the path to depression, better performance in managing daily life, transportation, finances, outdoor activity, and medication adherence could mitigate the impact of loneliness on depression to some extent. The negative moderation effects may be associated with multiple factors. On the one hand, some domains of IADL, such as managing finances and outdoor activities, are closely correlated with executive functions, such as sequencing and inhibition, and these domains show the largest discrepancy between those living with cognitive impairment and those living without impairment( 10 ). In addition, evidence has shown that greater cognitive performance is linked with better mental health. These results are consistent with those of previous studies showing that loneliness is associated with functional limitations and disabilities and suggest that the transition to a disabled state may trigger an increase in depressive symptoms( 29 ). Our study emphasizes the need to carefully examine individual domains of IADL disability and advanced interventions related to physical ability and physical exercise. Similarly, a study confirmed that a lower IADL, i.e., impairments in performing daily instrumental self-care activities, is also associated with poor subjective well-being (depression)( 30 ). Tailored services should be provided to older people with frailty in more complex tasks (e.g., financial and medication management and transportation) that require executive functioning( 31 ). On the other hand, elderly people with a low IADLT may not be able to experience many social activities as their heathy peers (Henning et al., 2016), which negatively affects their mental health. Physical disability may reduce their opportunities to participate in or complete daily life tasks alone, which may also be one of the factors that reduce IADL. At older ages, loneliness might not have the same impact on depression, as people tend to feel that their social circumstances compare favourably in terms of earlier expectations or relative to peers( 28 ). Maintaining moderate social activity and regular physical exercise is effective in postponing IADL disability( 32 ). According to activity theory, human beings need a sense of achievement and belonging within the social network, and elderly people are inclined to participate in activities that strengthen their social integration and adaptation. A Japanese cohort study indicated that elderly individuals with functional disabilities were less engaged in community management and activities, which implied that solitary status may lead to a decline in IADL function( 33 ). A weakened social network may isolate frail elderly individuals and increase their burden of depression. Some older people who live with their family still feel lonely because of the inappropriate quality of the support that they receive( 25 ). Our study subjects were 80 years old and who were likely to have experienced the death of a loved one. Although the community currently provides more professional and comprehensive facilities and services, we cannot deny the older people's adaptation to new things and their resistance and avoidance of things that are not within their cognitive scope. This sense of alienation may exacerbate loneliness and limit the daily performance of elderly people in different scenarios, increasing guilt, leading to more severe depression. We found that the population with higher IADL scores is relatively young and has higher levels of social support and education, although the correlation between the latter two factors was not statistically significant in this study. People with higher education levels may not expect to experience multimorbidity, as their peers are relatively healthier than people with lower education levels are and thus experience a greater impact on lifestyle and health value when they participate in non-home-based activities as much as possible( 34 ). Studies on older people have shown that individuals with sleep disorders and those older than 80 years are more likely to experience a decrease in IADL scores( 34 ). IADL limitations and depression symptoms were stronger in the older age category, patients with obvious sleep disorders, and patients with a high risk of malnutrition. These findings suggest that care programs for individuals living with frailty should pay attention to IADL limitations and depressive symptoms when considering people older than 80 years, those reporting insomnia problems, and those at risk of malnutrition. An important contribution of this study is that living arrangements modify the associations of loneliness with depression among people with CF, which has not been reported before( 35 ). In future research, scales with good reliability and validity should be adopted to evaluate more dimensions of loneliness, and factors associated with dynamic changes in loneliness should be further investigated. Loneliness has different impacts on older adults’ health according to different living arrangements, ages, and genders. One explanation for the moderating role of IADL may be that individuals at higher independent levels could act as a mechanism for reducing depression in other ways, such as social participation or physical activity. Loneliness has been related to psychological functional effects and mainly to the possibility of developing depression. Another perspective is that loneliness among elderly people cared for by domestic helpers may be related to family separation; therefore, developing corresponding interventions to improve physical and social support would be important for elderly people in the community. Therefore, these factors need to be considered when formulating related policies at the familial and societal levels. Limitations: Although the sample size in this study is considered adequate, the results may not be generalizable since a nonprobability sample was used after the districts were selected. In addition, the small sample size could have affected the study results. The questionnaire provides a general picture of how older people perceived their SRH, their sense of loneliness, and their level of IADL. Second, loneliness was assessed via one single question but not a scale, which made it difficult for us to evaluate other dimensions (e.g., the varying degrees) of loneliness and may have caused some bias. Conclusion In summary, older individuals with CF experience poor mental health and loneliness when living separately from their family. The extent to which loneliness negatively influences depression depends crucially on individuals’ functional limitations (IADL), with the IADL being more changeable by intervention than by psychological factors. This highlights the differences in social support and loneliness between elderly people living alone and those living with family. We should pay attention not only to the population with low IADL abilities but also to the importance of early cognitive and physical exercise interventions and to try to delay the time when elderly people lose their daily social and life abilities through exercise and social participation. These findings may increase awareness of the functional and mental health implications of community-dwelling older adults with CF. Additionally, this study highlights the need to design multidisciplinary care interventions that not only aim at enhancing social support but also mental and functional health while considering differences in age, education, and cognitive function. Thus, translating the study findings into concrete actions, such as redirecting care efforts related to physical function and social connection, will lead to a further positive impact on the life of individuals, offering them a successful ageing perspective despite health limitations. Declarations Clinical trial number: not applicable. Ethics approval and consent to participate: Approval number, 2022-PUMCH-B-130. The informed consent has been signed by participants. Consent for publication: The relevant document can be seen in Supplementary file 1. Availability of data and material: Data and relevant material will be made available on request from the corresponding author. Competing interests: The authors declare that there is no conflict of interest. Funding: National High Level Hospital Clinical Research, Peking Union Medical College Hospital Authors' contributions: ZYF: conceptualisation, formal analysis, investigation, writing–original draft, writing–review and editing, visualisation. HXP: conceptualisation, methodology, writing–review and editing. DHD: conceptualisation, formal analysis, investigation. LXX: conceptualisation, investigation, writing–review and editing, visualisation. LZ: conceptualisation, investigation, writing–review and editing. ZZY: writing–review and editing. YLF: investigation, conceptualisation, methodology. Acknowledgements: Thank you to all the experts and elderly people who participated in this study. References Nader MM, Cosarderelioglu C, Miao E, Whitson H, Xue QL, Grodstein F et al. Navigating and diagnosing cognitive frailty in research and clinical domains. Nat Aging. 2023;3(11):1325 – 33.10.1038/s43587-023-00504-z. 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Corbo I, Forte G, Favieri F, Casagrande M. Poor Sleep Quality in Aging: The Association with Mental Health. International journal of environmental research and public health. 2023;20(3).10.3390/ijerph20031661. Guo L, An L, Luo F, Yu B. Social isolation, loneliness and functional disability in Chinese older women and men: a longitudinal study. Age Ageing. 2021;50(4):1222 – 8.10.1093/ageing/afaa271. Terziotti C, Ceolin C, Devita M, Raffaelli C, Antenucci S, Bazzano S et al. Frailty, psychological well-being, and social isolation in older adults with cognitive impairment during the SARS-CoV-2 pandemic: data from the GeroCovid initiative. Psychogeriatrics: the official journal of the Japanese Psychogeriatric Society. 2023;23(6):1007 – 18.10.1111/psyg.13021. Chow SKY, Wong FMF, Choi EKY. Loneliness in Old Age, the Related Factors, and Its Association with Demographics and Districts of Residence. International journal of environmental research and public health. 2021;18(17).10.3390/ijerph18179398. Yan C, Johnson K, Jones VK. The Impact of Interaction Time and Verbal Engagement with Personal Voice Assistants on Alleviating Loneliness among Older Adults: An Exploratory Study. International journal of environmental research and public health. 2024;21(1).10.3390/ijerph21010100. Kil T, Yoon KA, Ryu H, Kim M. Effect of group integrated intervention program combined animal-assisted therapy and integrated elderly play therapy on live alone elderly. J Anim Sci Technol. 2019;61(6):379 – 87.10.5187/jast.2019.61.6.379. Melchiorre MG, Socci M, Lamura G, Quattrini S. Perceived Loneliness, Social Isolation, and Social Support Resources of Frail Older People Ageing in Place Alone in Italy. Healthcare (Basel). 2024;12(9).10.3390/healthcare12090875. Yin J, Lassale C, Steptoe A, Cadar D. Exploring the bidirectional associations between loneliness and cognitive functioning over 10 years: the English longitudinal study of ageing. International journal of epidemiology. 2019;48(6):1937 – 48.10.1093/ije/dyz085. Bien B, Bien-Barkowska K. Objective drivers of subjective well-being in geriatric inpatients: mobility function and level of education are general predictors of self-evaluated health, feeling of loneliness, and severity of depression symptoms. Quality of life research: an international journal of quality of life aspects of treatment, care and rehabilitation. 2016;25(12):3047 – 56.10.1007/s11136-016-1355-x. Kim J, Angel JL, Rote SM. A Longitudinal Study of Cognitive and Instrumental Activities of Daily Living Disablement Among the Oldest Mexican Americans. Journal of aging and health. 2022;34(2):196-205.10.1177/08982643211037512. Ren L, Li Z, Wu J, Duan L, Gao J. Knowledge, Attitudes, and Practices Among Elderly CHD Patients Towards Self-Perceived Health Abilities. 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Cite Share Download PDF Status: Published Journal Publication published 21 Feb, 2025 Read the published version in BMC Geriatrics → Version 1 posted Editorial decision: Revision requested 24 Oct, 2024 Reviews received at journal 24 Oct, 2024 Reviews received at journal 24 Oct, 2024 Reviewers agreed at journal 15 Oct, 2024 Reviewers agreed at journal 14 Oct, 2024 Reviewers invited by journal 04 Oct, 2024 Editor assigned by journal 01 Oct, 2024 Submission checks completed at journal 01 Oct, 2024 First submitted to journal 12 Sep, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5078090","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":376615763,"identity":"6b10bda0-325a-4f71-aebb-82a83afc8b6d","order_by":0,"name":"Yafang Zhao","email":"","orcid":"","institution":"Department of Ophthalmology, Chinese Academy of Medical Sciences \u0026 Peking Union Medical College Hospital, Beijing","correspondingAuthor":false,"prefix":"","firstName":"Yafang","middleName":"","lastName":"Zhao","suffix":""},{"id":376615764,"identity":"0fba5c5c-b1eb-4cb2-8e22-e02cfb05c712","order_by":1,"name":"Xiaopeng Huo","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABDklEQVRIie3RMUvEMBTA8VcC75bXq+CSwnG3OfconAiH9aO0BO4WUcTFMRA5Fz9Ai34IJ3FMCZxL0fXglhNXh3ZzUuMspKtD/mOSHyR5AD7fvyzYmc8rHGeK1bvua07RQPYRNjXQDNNkgGJa4mIU3+pekprgelwkER3sE5p5sjlxg0kpwFzIWX7ICBnRK8EGgrY7dbzkl1RPi7MjFa7f7vmWgjvJ4urRcS1+rnXYrC/BDJfJR7IlNtLIQgdBLkCHq+9CGppxyl8Iee4mZIkJV1g8WBKT1kR9hNM71GWDaazsJ1dSEKdaOd8yuRGsbe0oo8jYUcrjLHtWdds5COzlf5YC6Thvi7R73+fz+XzwA++CU/twy7oiAAAAAElFTkSuQmCC","orcid":"","institution":"Department of Nursing, Chinese Academy of Medical Sciences \u0026 Peking Union Medical College Hospital, Beijing","correspondingAuthor":true,"prefix":"","firstName":"Xiaopeng","middleName":"","lastName":"Huo","suffix":""},{"id":376615765,"identity":"899ee693-c350-4119-9693-42a0becc04eb","order_by":2,"name":"Hongdi Du","email":"","orcid":"","institution":"Department of medical care department, Chinese Academy of Medical Sciences \u0026 Peking Union Medical College Hospital, Beijing","correspondingAuthor":false,"prefix":"","firstName":"Hongdi","middleName":"","lastName":"Du","suffix":""},{"id":376615766,"identity":"9d28950f-6565-454a-9c37-511cb3802f5c","order_by":3,"name":"Xiaoxing Lai","email":"","orcid":"","institution":"Department of neurology, Chinese Academy of Medical Sciences \u0026Peking Union Medical College Hospital, Beijing","correspondingAuthor":false,"prefix":"","firstName":"Xiaoxing","middleName":"","lastName":"Lai","suffix":""},{"id":376615767,"identity":"3faccbb5-6dba-4c9a-9875-7b2ebccc1ec5","order_by":4,"name":"Zhen Li","email":"","orcid":"","institution":"Department of Department of Clinical Nutrition, Chinese Academy of Medical Sciences \u0026Peking Union Medical College Hospital, Beijing","correspondingAuthor":false,"prefix":"","firstName":"Zhen","middleName":"","lastName":"Li","suffix":""},{"id":376615768,"identity":"fd7ebe1c-cacb-4862-af0d-fb064278e158","order_by":5,"name":"Zhiyuan Zhang","email":"","orcid":"","institution":"Department of medical care department, Chinese Academy of Medical Sciences \u0026 Peking Union Medical College Hospital, Beijing","correspondingAuthor":false,"prefix":"","firstName":"Zhiyuan","middleName":"","lastName":"Zhang","suffix":""},{"id":376615769,"identity":"4aa46755-f51a-442f-9b6a-f215bc69e590","order_by":6,"name":"Longfei Yang","email":"","orcid":"","institution":"Department of Emergency, Chinese Academy of Medical Sciences \u0026 Peking Union Medical College Hospital, Beijing","correspondingAuthor":false,"prefix":"","firstName":"Longfei","middleName":"","lastName":"Yang","suffix":""}],"badges":[],"createdAt":"2024-09-12 13:40:35","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5078090/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5078090/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12877-025-05700-7","type":"published","date":"2025-02-21T15:56:58+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":69850792,"identity":"ce40ee7a-0000-43e1-baf5-41627312a239","added_by":"auto","created_at":"2024-11-25 23:31:23","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":273364,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend\u003c/p\u003e","description":"","filename":"Figure1.tif.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5078090/v1/e8754771e194ab895e78b75e.jpg"},{"id":77052749,"identity":"f1f18bb2-6aa4-4900-9e32-cdb06490ab78","added_by":"auto","created_at":"2025-02-24 16:24:24","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1435614,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5078090/v1/08c61be3-ac9e-466c-b36b-c95929e003d9.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Moderating effect of IADL on the relationship between depression and loneliness in cognitive frailty people","fulltext":[{"header":"Introduction","content":"\u003cp\u003eDue to the rapidly ageing population worldwide, an increasing proportion of older adults will exhibit a decrease in functional status and increased risks of frailty and cognitive impairment, among other age-related conditions. Cognitive frailty (CF) is defined as the conjunction of physical frailty with cognitive impairment but not the presence of a neurological condition. CF is a potentially reversible condition and is not necessarily an intermediate stage between normal ageing and dementia(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Although individuals with CF do not have a clear clinical diagnosis, it can still present with multidimensional deficits, including depression, decreased function, loneliness, and social and physical frailty. A few studies have reported that CF is more strongly associated with adverse health outcomes, such as disability in basic activities of daily living (BADL), Instrumental Activities of Daily Living Scale (IADL), low quality of life, and death, than cognitive impairment or physical frailty alone(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). On the other hand, compared with people who have already developed cognitive impairment, older adults with CF are relatively young, their physical functions are still intact, and their perceptions are normal. Therefore, they have a high demand for social participation, interpersonal communication, and a high quality of life, which we hope to help patients achieve(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe loss of physical and cognitive function may be related to the environment and can reflect the limited opportunities for older adults to participate at the community level(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). An increasing number of studies have shown that elderly people with cognitive decline are vulnerable to loneliness, even if the association is bidirectional. The potential reason for this association may be lifestyle factors (e.g., living alone, deceased friends and partners, chronic illnesses) that increase the risk of negative health outcomes associated with loneliness (e.g., poor immune function, mental health risks, heart disease)(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Elderly individuals with CF often experience declines in physical function, reduced mobility, and sensory and perceptual difficulties(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e); furthermore, dwelling and social institutions are incapable of providing adequate facilities or municipal services as the global population ages, which has an isolating effect on individuals, as their ability to go out and engage in social activities may be compromised(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn addition to loneliness, mental health problems are commonly reported among individuals with CF. Late-life depression increases the prevalence of physical illness, reduces quality of life, causes many medical conditions, and exacerbates disability. From a clinical and public health perspective, the factors influencing depressive symptoms among older adults should be explored to facilitate the early detection of depression and improve quality of life(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Recent studies have suggested that 16%~35% of individuals with frailty also experience coexisting depression and that the prevalence of depression in older adults with frailty is as high as 46.5%(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). The incidence of cognitive decline comorbid with depression among elderly individuals is high, and both factors influence each other. It has been reported that cognitive impairment occurs in 85%~94% of patients with acute depressive episodes and in 39%~44% of patients after a depressive episode has subsided. Depression among China\u0026rsquo;s elderly population is associated with the trajectory of changes in cognitive function(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAs CF represents a decline in physical function, IADL, which include cooking, laundry, transport, and finance management, are likely affected among individuals with CF. Deficits in performing these self-care-related IADL are more pronounced among elderly individuals, and this disability is independently associated with depression(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). A cross-sectional study of 207 Japanese Americans (aged\u0026thinsp;\u0026ge;\u0026thinsp;68 years) revealed that older adults with high levels of functional status in IADL have lower odds of depressive symptoms (OR: 0.2, 95% CI: 0.09\u0026ndash;0.50)(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). People with disabilities in complex activities and with reduced efficiency of cognitive functions, who are more dependent on others, and who have greater deficits in self-care are more likely to be depressed. Previous research has confirmed that older people with more severe functional impairment are more likely to experience depressive symptoms(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). A longitudinal study from Western countries revealed that loneliness was associated with an increase in ADL difficulties. It seems that loneliness and decreased daily living ability are common risk factors for depression. However, little is known about the associations among depressive symptoms, loneliness, and IADL disabilities among community-dwelling older people with cognitive decline and physical dysfunction.\u003c/p\u003e \u003cp\u003eLoneliness and depression are more common in elderly people with CF than in cognitively normal elderly people. Moreover, the ability to use tools among elderly people seems to be related to depression, but this relationship has not been examined in detail among individuals with cognitive decline. The relationships among the deterioration of cognitive functions, physical functions, mental functions, and independence in everyday life should be explored. Therefore, this study aimed to analyse the influence of loneliness on depressive symptoms and the moderation effect of IADL on the direction from loneliness to depression among older adults with CF.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy population\u003c/h2\u003e \u003cp\u003eThe study is a cross-sectional survey of frailty prevalence and relevant factors among community-dwelling elderly people that was initiated in July 2023 to December 2023. This survey finally included 529 participants, the inclusion criteria were: a) aged 65 years or above; b) be able to complete the survey with the aid from research assistants; c) not at the end stage of serious diseases; d) assigned informed consent and voluntary to participate; and e) the MoCA score\u0026lt;26, for those with less than 12 years education, an additional 1 point will be added to the original score, and the Clinical Dementia Rating Scale (CDR) was on 0.5 score at the same time. The Fried type score was \u0026ge;\u0026thinsp;3. The exclusion criteria were: a) clinically diagnosed with dementia or mental health illness, b) with severe organ dysfunction and in the final stage of the disease, c) with severe hearing, vision, and language impairment or other physical conditions that hold back them to complete the investigation. According to the previous prevalence of frailty was 10%, and the formula \u003cimg src=\"data:image/png;base64,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\" width=\"133\" height=\"30\"\u003e, the minimum sample size for the cross-sectional survey would be 865 to screen people with cognitive frailty among general elderly.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eMeasures\u003c/h3\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eDemographic characteristics:\u003c/h2\u003e \u003cp\u003eThe general sociodemographic information were recorded, including gender, age, education level, job before retirement, living status, activity status, body mass index, chronic disease history, smoking and alcohol history, and medication usage.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eFrailty phenotype:\u003c/h3\u003e\n\u003cp\u003eFrailty was assessed and defined using a modified Fried frailty phenotype comprising five criteria: slowness, weakness, exhaustion, weight loss, and low activity(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Based on these criteria, participants received a sum score ranging from zero to five. For each of the characteristics, one point is given if the measure is positive for frailty, in the absence of any characteristic suggestive of frailty, persons are robust, whereas persons with 3\u0026ndash;5 characteristics are considered frail. The presence of 1 or 2 characteristics indicates a prefrail condition.\u003c/p\u003e\n\u003ch3\u003eShort-form Geriatric Depression Scale(GDS-15):\u003c/h3\u003e\n\u003cp\u003eThe short-form geriatric depression scale involved 15 items (GDS-15) which were extracted from the 30-item version, and high correlation index was found between the GDS full and short forms (r\u0026thinsp;=\u0026thinsp;0.91, P\u0026thinsp;\u0026lt;\u0026thinsp;0.01). The Cronbach\u0026rsquo;s alpha was 0.7(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e)and it has been widely used to screen depression among elderly in nursing home and medical institutions. The GDS-15 score range from 0 to 15 and higher score referred to severe depression.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eAthens Insomnia Scale (AIS-8):\u003c/h2\u003e \u003cp\u003eThe Athens Insomnia Scale contains 8 items, and the first five address the participant\u0026rsquo;s nighttime symptoms (difficulty in sleep initiation, difficulty in maintaining sleep and early morning awakening), while the last three items address the daytime impact due to any reported sleep disturbances. The respondents were required to provide a positive rating if they had experienced a sleep difficulty described in each item at least three times a week during the last month. A maximum total score of 24, indicating the most severe symptoms of insomnia, was possible, while a cut-off point of \u0026ge;\u0026thinsp;6 represented a minimum criterion for the confirmation of insomnia symptoms(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eInstrumental Activity of Daily Living (IADL):\u003c/h3\u003e\n\u003cp\u003eThe IADL scale was used to evaluate instrumental living activities consisting of 8 questions. The response spectrum is based on a 5-Likert, in the area of using the telephone (3 items), shopping(3 items), food preparation(3 items), home activities(4 items), washing clothes(2 items), transportation (4 items), drug administration (2 items), and financial management (2 items). The total score ranged between 0 to 23, and higher score indicates the greater of a person\u0026rsquo;s abilities. The Cronbach\u0026rsquo;s alpha was 0.75(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e\n\u003ch3\u003eSocial Support Scale(SSRS):\u003c/h3\u003e\n\u003cp\u003eThe scale was developed to assess how much support respondents received from participants\u0026rsquo; family, friends, and social contexts, and SSRS consists of 10 items with a total score of 60. The level of social support that individuals expect and receive can be understood through this scale. Higher score of SSRS indicates better level of social support. The Cronbach\u0026rsquo;s alpha for the present study was 0.788(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e).\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eLubben Social network scale:\u003c/h2\u003e \u003cp\u003eWe used Lubben Social network scale to measure individual\u0026rsquo;s perceived of social engagement including family and friends by self-report. The scale consists of 12 items with response to each item rating from 0 (less social engagement) to 5 (more social engagement). Higher total score indicating more social engagement. The Cronbach alpha for the LSNS is 0.7(\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eLoneliness assessment:\u003c/h2\u003e \u003cp\u003eThe loneliness was evaluated by the question \u0026ldquo;How often do you feel alone?\u0026rdquo; The response was a Likert-5 option, 0 means \u0026ldquo;not at all\u0026rdquo;, where 4 refers to \u0026ldquo;always\u0026rdquo;. Higer scores indicates higher level of loneliness.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eFirst, the demographic characteristics data was analyzed by number and percentage, the other data collected was analyzed using a descriptive analysis of means and standard deviation for each variable to be analyzed. We divided participants into 2 sub-groups on the basis of frailty type (pre-frailty vs. frailty), and R\u0026times;C χ\u0026sup2; Test was used to compare the difference between two sub-groups. Second, the spearman correlation analysis was conducted among the variables which are sleep, loneliness, IADL, social net, social support, age, and depression. The linear regression models reported in the study considered depression as the dependent variable, three models were calculated. The first model, sleep, loneliness and social network were selected enter the model. In the second model included the moderation variable of IADL, and the third model, the moderation effect of IADL and loneliness was analyzed included in the model.\u003c/p\u003e \u003cp\u003eThe statistical method of the third model included moderation analysis using the PROC REG step in SAS 9.4. For the moderation effect, variables were centered to the mean and interactions were created by calculating the product of loneliness and IADL. The liner regression analysis incorporated two variables and the moderation variable. To determine significant interactions, a simple slope analysis was performed at low (\u0026minus;\u0026thinsp;1 SD), and high (+\u0026thinsp;1 SD) levels of the moderator45. Hypothesis was tested based on confidence intervals, effect size and significant interactions (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eEthical consideration\u003c/h2\u003e \u003cp\u003e This research was reviewed and approved by the ethics committee of the Peking Union Medical College Hospital on 8 October, 2022 (project: National High Level Hospital Clinical Research Funding, approval number: 2022-PUMCH-B-130)\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eParticipant characteristics\u003c/h2\u003e \u003cp\u003eTotal 529 elderly considered as cognitive frailty involved in the final statistical analysis. Descriptive statistics of demographics, sleep, depression level, IADL, and loneliness are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, and the difference of comparing those variables based on frailty type were also conducted. The age, IADL scores, job types, and education level were significantly difference between subtypes of frailty level. When compared the characteristics of considered frailty (N\u0026thinsp;=\u0026thinsp;146) with pre-frail, the considered frailty elderly were older than pre-frail (84.18 vs. 80.27, P\u0026thinsp;\u0026lt;\u0026thinsp;.001), the level of dependable indicated by IADL scores was worse than pre-frail (5.71 vs.7.01, P\u0026thinsp;\u0026lt;\u0026thinsp;.001), major participant with bachelors degree were considered as pre-frail (P\u0026thinsp;\u0026lt;\u0026thinsp;.001). The levels of depress and insomnia were presented worse among considered frailty, most participants among pre-frail showed a light degree of loneliness and a stronger social net.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic characteristics of frailty elderly (N\u0026thinsp;=\u0026thinsp;529)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePre-frail\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eConsidered-frailty\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOverall, N\u0026thinsp;=\u0026thinsp;529\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;146 (28%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;383 (72%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e81.34\u0026thinsp;\u0026plusmn;\u0026thinsp;6.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e84.18\u0026thinsp;\u0026plusmn;\u0026thinsp;5.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e80.27\u0026thinsp;\u0026plusmn;\u0026thinsp;6.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.169\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e321 (60.68%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e96 (29.91%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e225 (70.01%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e208 (39.32%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50 (24.03%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e158 (75.97%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBMI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.519\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;18.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24 (4.51%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (29.17%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17 (70.83%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e18.5\u0026thinsp;~\u0026thinsp;25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e321 (60.68%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e87 (27.10%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e234 (72.90%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e184 (34.78%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50 (27.17%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e134 (72.83%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSmoking or drinking\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.463\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e504 (95.27%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e137 (27.18%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e367 (72.82%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25 (4.73%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (36.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16 (64.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMulti-tablet\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.579\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e244 (46.12%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e64 (26.23%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e180 (73.77%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e285 (53.88%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e82 (28.77%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e203 (71.23%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLiving status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLiving alone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e75 (14.18%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (25.33%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e56 (74.64%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLiving with domestic helper(s)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40 (7.56%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (40%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24 (60%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLiving with family\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e415 (78.45%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e112 (26.98%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e303 (73.02%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOccupation before retirement\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdministrative personnel\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e179 (33.65%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33 (18.44%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e145 (81.56%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWorker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e269 (50.85%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e66 (24.54%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e203 (75.46%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003efarmer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e69 (13.04%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41 (59.42%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28 (40.58%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (2.46%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (46.15%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (53.85%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEducation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e44(8.32%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28 (63.64%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16 (36.36%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJunior high school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e87 (16.45%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32 (36.78%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e55 (63.22%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSenior high school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e216 (40.83%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e53 (24.54%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e163 (75.46%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBachelor or higher\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e182 (34.40%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33 (18.13%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e149 (81.87%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDepression\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.76\u0026thinsp;\u0026plusmn;\u0026thinsp;1.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.00\u0026thinsp;\u0026plusmn;\u0026thinsp;1.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.67\u0026thinsp;\u0026plusmn;\u0026thinsp;1.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.209\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eIADL\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.65\u0026thinsp;\u0026plusmn;\u0026thinsp;1.91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.71\u0026thinsp;\u0026plusmn;\u0026thinsp;2.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7.01\u0026thinsp;\u0026plusmn;\u0026thinsp;1.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSleep\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u0026thinsp;\u0026plusmn;\u0026thinsp;1.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.47\u0026thinsp;\u0026plusmn;\u0026thinsp;1.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.80\u0026thinsp;\u0026plusmn;\u0026thinsp;1.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.154\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAlone\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.118\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0\u0026ndash;1 (scores)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e355 (67.11%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e86 (24.22%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e259 (75.78%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u0026ndash;4 (scores)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e174 (36.89%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50 (28.74%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e124 (71.26%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003ePreliminary analyses\u003c/h2\u003e \u003cp\u003eThe Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows the results of the Spearman correlation analysis. All the key variables were significantly correlated with one another, and there were moderate-strength associations observed between IADT, age, and depression. The correlations between sleep, depression, loneliness, and age were weak.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe correlation analysis of variables (N\u0026thinsp;=\u0026thinsp;529)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSleep\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDepress\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSocial\u003c/p\u003e \u003cp\u003eSupport\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSocial\u003c/p\u003e \u003cp\u003enet\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eIADL\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eLoneliness\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eSleep\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.113\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.054\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-0.067\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-0.056\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.009\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.1219\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.1926\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.998\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eDepress\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e0.113\u003c/b\u003e\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.058\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-0.073\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-0.253\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.101\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e0.009\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.1804\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.0912\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eSocial Support\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.054\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.058\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-0.01441\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.01031\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-0.059\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.209\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.180\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.740\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.812\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.172\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eSocial net\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.067\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.073\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.014\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-0.035\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.121\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.091\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.749\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.412\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.995\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eIADL\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.056\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e-0.253\u003c/b\u003e\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.010\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-0.035\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-0.087\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.192\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.0001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.812\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.412\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.043\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eLoneliness\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.101\u003c/b\u003e\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.059\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e-0.087\u003c/b\u003e\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.998\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.020\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.172\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.995\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.043\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.054\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.031\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.026\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.004\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e-0.231\u003c/b\u003e\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.0191\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.2144\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.482\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.5424\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.915\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.802\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003e\u003csup\u003e\u003cem\u003e*\u003c/em\u003e\u003c/sup\u003e\u003cem\u003eP\u0026thinsp;\u0026lt;\u0026thinsp;.05\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eModeration analyses\u003c/h2\u003e \u003cp\u003eThe level of IADL was found to moderate the relationship between loneliness and depression (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The three models presented in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e indicate the regression coefficients of the variables that were considered in the hypotheses of this study. In model 1, only the control and independent variables were considered, and both variables were significant. In the case of sleep, the regression coefficient was β\u0026thinsp;=\u0026thinsp;0.04, P\u0026thinsp;\u0026lt;\u0026thinsp;001; for social networks, the regression coefficient was β=-0.02, P\u0026thinsp;=\u0026thinsp;0.03; and for loneliness, the regression coefficient was β=-0.02, P\u0026thinsp;=\u0026thinsp;.03. In model 2, we added the moderation variable IADL into the regression analysis. The regression coefficient for sleep was β\u0026thinsp;=\u0026thinsp;0.036, P\u0026thinsp;=\u0026thinsp;.02; for social networks, the regression coefficient was β=-0.02, P=-0.013, P\u0026thinsp;\u0026lt;\u0026thinsp;.01; for loneliness, the regression coefficient was β\u0026thinsp;=\u0026thinsp;0.145, P\u0026thinsp;=\u0026thinsp;.02; and for the moderator IADL, the regression coefficient was β=-0.191, P\u0026thinsp;\u0026lt;\u0026thinsp;.01. In model 3, which was based on Hayes\u0026rsquo; linear regression analysis, we added the interaction variable of IADL * loneliness, which yielded a significant coefficient of β=-0.116, P\u0026thinsp;\u0026lt;\u0026thinsp;.01. Most of the variables included in the model were significant, except for social network (β=-0.024, P\u0026thinsp;=\u0026thinsp;0.19). The regression coefficient for the interaction of IADL* loneliness was β=-0.116, P\u0026thinsp;\u0026lt;\u0026thinsp;.01, which indicated that the effect of the moderator IADL on the relationship between loneliness and depression significantly differed based on the IADLT.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eModeration graph of the moderation for the effect of IADL in the relationship between loneliness and depress (N\u0026thinsp;=\u0026thinsp;529)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"13\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c13\" colnum=\"13\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eModel 1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eModel 2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003eModel 3\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eβ\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003et\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLLCI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eULCI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eβ\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003et\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eLLCI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eULCI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003eβ\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c11\"\u003e \u003cp\u003et\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c12\"\u003e \u003cp\u003eLLCI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c13\"\u003e \u003cp\u003eULCI\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSleep\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.04\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.036\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e2.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.028\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.078\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.033\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e2.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e0.022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e0.068\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSocial network\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e-0.02\u003c/em\u003e\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e-1.84\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e-0.12\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003e-0.016\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003e-0.013\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003e-1.81\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e\u003cem\u003e-0.126\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e\u003cem\u003e0.590\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e-0.024\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e-2.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e-0.039\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e0.489\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLoneliness\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.19\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.145\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.026\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.358\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.922\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e2.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e0.095\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e0.932\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eIADL\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e-0.191\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e-5.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e-0.236\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e-0.022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e-0.086\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e-2.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e-0.192\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e-0.032\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eIADL*Loneliness\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e-0.116\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e-2.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e-0.756\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e-0.056\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eR2\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eR2\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eR2\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"13\"\u003e\u003csup\u003e\u003cem\u003e*\u003c/em\u003e\u003c/sup\u003e\u003cem\u003eP\u0026thinsp;\u0026lt;\u0026thinsp;.05\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eFurthermore, \u003cb\u003eFig.\u0026nbsp;1\u003c/b\u003e shows that when the IADL is high, the impact of loneliness on depression is weaker. Conversely, when the IADL is low, the impact of loneliness on depression is more significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study aimed to examine the moderating effect of IADL on the relationship between loneliness and depression. On the basis of previous reports on the psychological, physiological, and social factors of frail populations, further exploration of regulatory factors has provided insights beyond the flat description results, and studies have examined factors associated with the characteristics of frail populations. This study further highlights the integration and mutual influence of the weakened population from multiple perspectives \u0026ndash; including social, physiological, and psychological perspectives \u0026ndash; thus suggesting that there is a synergistic effect of physical health and social participation on the mental health of elderly individuals. The aim of this study was to highlight regulatory factors that may improve the mental health of elderly people with prefrailty or frailty, thus promoting their successful ageing. The results reported in the current study contribute to the literature by examining the characteristics and heterogeneity between different stages of frailty in people. Furthermore, we found that the path from loneliness to depression is mediated by IADL.\u003c/p\u003e \u003cp\u003eThe average age of our participants was over 80 years, which inevitably led to a high incidence of geriatric syndrome, as most of the elderly reported insomnia, depressive symptoms, and worse physical ability than did those reported in previous studies(\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Severe physical ability and movement barriers somewhat hinder elderly people from participating in social interactions, and living separate from family members led to loneliness and depression. Previous studies reported that frailty was associated with increased feelings of loneliness, social isolation, and depression, and prefrail patients were more likely to report neuropsychiatric disorders, such as sleep disorders. Prospective findings have shown a link between loneliness and a decline in gait speed or mobility and increased difficulty with ADLs(\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). These findings are consistent with our results(\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e), and further exploration of potential reasons may be due to social isolation. A study conducted among older adults reported high prevalence rates of loneliness and social isolation, which were driven by the loss of social partners, the reduction in social contact, and physical limitations(\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). A person\u0026rsquo;s health status and loneliness are interrelated, as loneliness can lead to pain, depression, and mental health problems(\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Older people who reported greater feelings of loneliness were eight times more likely to experience worse mental health than those who experienced less loneliness. The older adults in our study may have experienced a loss of relationship or interest. Moreover, evidence has shown that the absence of an intimate relationship results in a greater level of loneliness(\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Some informal social support, such as group integrated intervention programs, could not only improve their social interactions but also strengthen their cognitive and physical capabilities(\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Active engagement in social and cognitive activities was found to be negatively related to both loneliness and hopelessness in older Chinese people(\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe novelty of this study lies in the finding that IADL is associated not only with depression and loneliness but also with the balance between the two mental health conditions. When IADL is involved in the path to depression, better performance in managing daily life, transportation, finances, outdoor activity, and medication adherence could mitigate the impact of loneliness on depression to some extent. The negative moderation effects may be associated with multiple factors. On the one hand, some domains of IADL, such as managing finances and outdoor activities, are closely correlated with executive functions, such as sequencing and inhibition, and these domains show the largest discrepancy between those living with cognitive impairment and those living without impairment(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). In addition, evidence has shown that greater cognitive performance is linked with better mental health. These results are consistent with those of previous studies showing that loneliness is associated with functional limitations and disabilities and suggest that the transition to a disabled state may trigger an increase in depressive symptoms(\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). Our study emphasizes the need to carefully examine individual domains of IADL disability and advanced interventions related to physical ability and physical exercise. Similarly, a study confirmed that a lower IADL, i.e., impairments in performing daily instrumental self-care activities, is also associated with poor subjective well-being (depression)(\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). Tailored services should be provided to older people with frailty in more complex tasks (e.g., financial and medication management and transportation) that require executive functioning(\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOn the other hand, elderly people with a low IADLT may not be able to experience many social activities as their heathy peers (Henning et al., 2016), which negatively affects their mental health. Physical disability may reduce their opportunities to participate in or complete daily life tasks alone, which may also be one of the factors that reduce IADL. At older ages, loneliness might not have the same impact on depression, as people tend to feel that their social circumstances compare favourably in terms of earlier expectations or relative to peers(\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). Maintaining moderate social activity and regular physical exercise is effective in postponing IADL disability(\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). According to activity theory, human beings need a sense of achievement and belonging within the social network, and elderly people are inclined to participate in activities that strengthen their social integration and adaptation. A Japanese cohort study indicated that elderly individuals with functional disabilities were less engaged in community management and activities, which implied that solitary status may lead to a decline in IADL function(\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). A weakened social network may isolate frail elderly individuals and increase their burden of depression.\u003c/p\u003e \u003cp\u003eSome older people who live with their family still feel lonely because of the inappropriate quality of the support that they receive(\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Our study subjects were 80 years old and who were likely to have experienced the death of a loved one. Although the community currently provides more professional and comprehensive facilities and services, we cannot deny the older people's adaptation to new things and their resistance and avoidance of things that are not within their cognitive scope. This sense of alienation may exacerbate loneliness and limit the daily performance of elderly people in different scenarios, increasing guilt, leading to more severe depression.\u003c/p\u003e \u003cp\u003eWe found that the population with higher IADL scores is relatively young and has higher levels of social support and education, although the correlation between the latter two factors was not statistically significant in this study. People with higher education levels may not expect to experience multimorbidity, as their peers are relatively healthier than people with lower education levels are and thus experience a greater impact on lifestyle and health value when they participate in non-home-based activities as much as possible(\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). Studies on older people have shown that individuals with sleep disorders and those older than 80 years are more likely to experience a decrease in IADL scores(\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). IADL limitations and depression symptoms were stronger in the older age category, patients with obvious sleep disorders, and patients with a high risk of malnutrition. These findings suggest that care programs for individuals living with frailty should pay attention to IADL limitations and depressive symptoms when considering people older than 80 years, those reporting insomnia problems, and those at risk of malnutrition.\u003c/p\u003e \u003cp\u003eAn important contribution of this study is that living arrangements modify the associations of loneliness with depression among people with CF, which has not been reported before(\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). In future research, scales with good reliability and validity should be adopted to evaluate more dimensions of loneliness, and factors associated with dynamic changes in loneliness should be further investigated. Loneliness has different impacts on older adults\u0026rsquo; health according to different living arrangements, ages, and genders. One explanation for the moderating role of IADL may be that individuals at higher independent levels could act as a mechanism for reducing depression in other ways, such as social participation or physical activity. Loneliness has been related to psychological functional effects and mainly to the possibility of developing depression. Another perspective is that loneliness among elderly people cared for by domestic helpers may be related to family separation; therefore, developing corresponding interventions to improve physical and social support would be important for elderly people in the community. Therefore, these factors need to be considered when formulating related policies at the familial and societal levels.\u003c/p\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eLimitations:\u003c/h2\u003e \u003cp\u003eAlthough the sample size in this study is considered adequate, the results may not be generalizable since a nonprobability sample was used after the districts were selected. In addition, the small sample size could have affected the study results. The questionnaire provides a general picture of how older people perceived their SRH, their sense of loneliness, and their level of IADL. Second, loneliness was assessed via one single question but not a scale, which made it difficult for us to evaluate other dimensions (e.g., the varying degrees) of loneliness and may have caused some bias.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn summary, older individuals with CF experience poor mental health and loneliness when living separately from their family. The extent to which loneliness negatively influences depression depends crucially on individuals\u0026rsquo; functional limitations (IADL), with the IADL being more changeable by intervention than by psychological factors. This highlights the differences in social support and loneliness between elderly people living alone and those living with family. We should pay attention not only to the population with low IADL abilities but also to the importance of early cognitive and physical exercise interventions and to try to delay the time when elderly people lose their daily social and life abilities through exercise and social participation.\u003c/p\u003e \u003cp\u003eThese findings may increase awareness of the functional and mental health implications of community-dwelling older adults with CF. Additionally, this study highlights the need to design multidisciplinary care interventions that not only aim at enhancing social support but also mental and functional health while considering differences in age, education, and cognitive function. Thus, translating the study findings into concrete actions, such as redirecting care efforts related to physical function and social connection, will lead to a further positive impact on the life of individuals, offering them a successful ageing perspective despite health limitations.\u003c/p\u003e "},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eClinical trial number:\u0026nbsp;\u003c/strong\u003enot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e Approval number, 2022-PUMCH-B-130. The informed consent has been signed by participants.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003eThe relevant document can be seen in \u003cstrong\u003eSupplementary file 1.\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material:\u0026nbsp;\u003c/strong\u003eData and relevant material will be made available on request from the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u0026nbsp;\u003c/strong\u003eThe authors declare that there is no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003eNational High Level Hospital Clinical Research, Peking Union Medical College Hospital\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eZYF: conceptualisation, formal analysis, investigation, writing\u0026ndash;original draft, writing\u0026ndash;review and editing, visualisation. HXP: conceptualisation, methodology, writing\u0026ndash;review and editing. DHD: conceptualisation, formal analysis, investigation. LXX: conceptualisation, investigation, writing\u0026ndash;review and editing, visualisation. LZ: conceptualisation, investigation, writing\u0026ndash;review and editing. ZZY: writing\u0026ndash;review and editing. YLF: investigation, conceptualisation, methodology.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThank you to all the experts and elderly people who participated in this study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eNader MM, Cosarderelioglu C, Miao E, Whitson H, Xue QL, Grodstein F et al. Navigating and diagnosing cognitive frailty in research and clinical domains. Nat Aging. 2023;3(11):1325\u0026thinsp;\u0026ndash;\u0026thinsp;33.10.1038/s43587-023-00504-z.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChen C, Park J, Wu C, Xue Q, Agogo G, Han L et al. Cognitive frailty in relation to adverse health outcomes independent of multimorbidity: results from the China health and retirement longitudinal study. Aging (Albany NY). 2020;12(22):23129\u0026thinsp;\u0026ndash;\u0026thinsp;45.10.18632/aging.104078.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAi F, Li E, Dong A, Zhang H. Association between disability and cognitive function in older Chinese people: a moderated mediation of social relationships and depressive symptoms. Frontiers in public health. 2024;12:1354877.10.3389/fpubh.2024.1354877.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFowler Davis S, Benkowitz C, Holland C, Gow A, Clarke C. A Scoping Review on the Opportunities for Social Engagement and Cognitive Frailty in Older Adults. 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BMC geriatrics. 2022;22(1):59.10.1186/s12877-021-02742-5.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-geriatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bgtc","sideBox":"Learn more about [BMC Geriatrics](http://bmcgeriatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bgtc/default.aspx","title":"BMC Geriatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Cognitive, Moderation analysis, Depression, IADL, Loneliness, Frailty, Older people","lastPublishedDoi":"10.21203/rs.3.rs-5078090/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5078090/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e \u003cp\u003eIdentification of depression and loneliness among people with cognitive frailty could prevent negative psychological and physical health outcomes. Few studies have focused on physical and mental health together among people with cognitive frailty, little is known about the role of daily activity in the association between depression and loneliness among elderly individuals with cognitive frailty.\u003c/p\u003e\u003ch2\u003eObjectives:\u003c/h2\u003e \u003cp\u003eTo determine the direct effect of loneliness on depression among community-dwelling older adults with cognitive frailty as well as the moderating effect of daily activity.\u003c/p\u003e\u003ch2\u003eDesign, setting, participants, and measurements:\u003c/h2\u003e \u003cp\u003eThis cross-sectional study included 529 adults aged 65 years and older from community-dwelling population who were screened for cognitive frailty, and was conducted from July 2023 to December 2023. The participants were assessed using validation instruments for measuring main variables: Short-form Geriatric Depression Scale, loneliness questionnaire, Athens Insomnia Scale, Instrumental Activities of Daily Living (IADL), Social Support Scale, and sociodemographic characteristics.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe IADL, depression, insomnia, and loneliness scores were lower among individuals with frailty than among individuals with prefrailty. The interaction effect of IADL* loneliness illustrated that the moderating effect of IADL on the relationship between loneliness and depression significantly differed based on the IADL score. When IADL scores were low, the impact of loneliness on depression was more significant.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThe integrity of physical and social connections has a protective effect on the mental health of elderly with cognitive frailty. It is necessary to pay attention to disability and loneliness among elderly individuals. Targeted interventions for improving physical activity and social participation seem to be practical and feasible solutions to alleviate depressive symptoms.\u003c/p\u003e","manuscriptTitle":"Moderating effect of IADL on the relationship between depression and loneliness in cognitive frailty people","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-11-25 23:31:18","doi":"10.21203/rs.3.rs-5078090/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-10-25T03:33:48+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-10-24T09:39:06+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-10-24T08:28:07+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"212123820260656067842764885983417813219","date":"2024-10-15T10:59:58+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"323671204657206416271218040142725820174","date":"2024-10-14T11:30:53+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-10-04T13:50:01+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-10-01T05:41:19+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-10-01T04:27:24+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Geriatrics","date":"2024-09-12T13:39:05+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-geriatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bgtc","sideBox":"Learn more about [BMC Geriatrics](http://bmcgeriatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bgtc/default.aspx","title":"BMC Geriatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"711d1261-ea5a-40cd-9a78-d788c64d70eb","owner":[],"postedDate":"November 25th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-02-24T16:05:59+00:00","versionOfRecord":{"articleIdentity":"rs-5078090","link":"https://doi.org/10.1186/s12877-025-05700-7","journal":{"identity":"bmc-geriatrics","isVorOnly":false,"title":"BMC Geriatrics"},"publishedOn":"2025-02-21 15:56:58","publishedOnDateReadable":"February 21st, 2025"},"versionCreatedAt":"2024-11-25 23:31:18","video":"","vorDoi":"10.1186/s12877-025-05700-7","vorDoiUrl":"https://doi.org/10.1186/s12877-025-05700-7","workflowStages":[]},"version":"v1","identity":"rs-5078090","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5078090","identity":"rs-5078090","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}