Functional disability and depressive symptoms among centenarians in Nanjing, China: The mediating role of leisure activities and attitudes toward aging

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Methods The data were obtained from a cross-sectional household survey of 185 centenarians in Nanjing. We used OLS and structural equation modeling to examine the associations between functional disability, leisure activities, attitudes toward aging, and depressive symptoms. Results Functional disability was positively associated with depressive symptoms (b = 0.24, p < 0.001). Both leisure activities (34.2%) and attitudes toward aging (82.3%) partially mediated the association between functional disability and depressive symptoms among centenarians. Conclusions Our findings suggest that engaging in leisure activities and fostering a positive attitude toward aging may help very old adults maintain their mental well-being, despite declines in physical functioning. functional disability depressive symptoms leisure activities attitudes toward aging centenarian Figures Figure 1 Figure 2 1. Introduction With rising living standard, lifestyle changes, and medical advancements, more people around the world are living exceptionally long life. In China, the number of centenarians reached 118,900 at the end of 2020, a 3.3-fold times from 2010. Centenarians are often seen as models of successful aging due to their remarkable longevity, but they exhibit significant variations in functional and cognitive abilities [ 1 ]. For many centenarians, extended life expectancy is often accompanied by increased morbidity and decreased functionality [ 2 ]. These declines impact not only survival, but also key aspects of quality of life, including independent living and overall well-being [ 3 ]. Depression is a significant contributor to the global burden of disease [ 4 ]. Despite ample evidence linking functional disability and depressive symptoms [ 5 , 6 ], few studies have explored whether this association exists in extremely old ages. Physical function declines with age. Indeed, centenarians often experience severe physical health challenges. For example, in a Japanese centenarian sample, approximately one-third of the centenarians were totally physically dependent, and a quarter of them functioned independently [ 7 ]. The Second Heidelberg Centenarian Study showed that the average physical activities of daily living (PADL) and instrumental activities of daily living (IADL) scores of centenarians were at a low to medium level [ 8 ]. Besides, studies have also shown that functional disability may be a risk factor for depressive symptoms, and its possible mechanisms reveal that functional disability as a stressful event increases the likelihood of developing depressive symptoms. However, whether functional disability is associated with the onset of depressive symptoms among centenarians deserves further investigation. Leisure activities and the way older adults perceive their aging process have been suggested to have great implications for their psychological well-being. Using a sample of centenarians collected in Nanjing, the aims of this study are: (1) What is the relationship between functional disability and depressive symptoms in centenarians? (2) what are the factors that mediate the association between functional disability and depressive symptoms? In this study, we aim to specifically explore how functional disability is associated with the emergence of depressive symptoms through leisure activities and attitudes toward aging. Based on the stress process theory, we posit that functional disability is a chronic stress that disrupts engagement in leisure activities, and positive attitudes toward aging, which in turn, amplify depressive symptoms. 2. Functional disability, leisure activities, attitudes toward aging, and depressive symptoms Functional disability refers to the acquired difficulties that older adults have in performing basic and complex tasks required for daily living [ 9 ], including challenges in basic activities of daily living (ADL) and instrumental activities of daily living (IADL) [ 10 ]. Functional disability has long been recognized as a significant stressor contributing to unhappiness and depression in later life [ 11 , 12 ]. A substantial body of studies provide strong evidence that physical dysfunction is associated with increased depressive symptoms in old age [ 13 – 16 ]. On the one hand, inability to perform daily activities triggers feelings of incompetence and dependence, leading to distress and pessimism [ 17 ]. In contrary, chronic depression reduces leisure activities participation [ 18 ], limits interpersonal interactions [ 19 ], and impairs cognitive function [ 20 ], and further hinder the ability to conduct ADL and IADL independently. While the relationship between functional disability and depressive symptoms is well-documented, there remains a need to better understand how functional disability specifically affects depressive symptoms among centenarians. The Stress Process Theory is a theoretical framework for explaining and analyzing how individuals experience, cope with, and adapt to life stress [ 21 ]. It focuses on how stressor, such as functional disability, affect individuals’ mental health through some resources (behavioral responses and long-term psycho-social adaptation) [ 22 – 25 ]. However, there is limited understanding of the role that these resources, such as leisure activities and attitudes toward aging, play in the association between functional disability and depressive symptoms. 2.1 Leisure activities (LA) Leisure activities are defined as participation in activities that promote interaction with others in society or the community [ 26 ]. Older adults’ leisure activities is greatly affected by their functional health status. Both cross-sectional and longitudinal studies have found that age-related functional decline not only reduces the frequency of leisure activities [ 27 , 28 ], but also limits the types of activities that individuals can engage in, such as sports and housework [ 29 ]. A British study also found that older adults are more likely to meet moderate or vigorous leisure activity guidelines if they do not have chronic health problems and severe mobility impairments [ 30 ]. Leisure activities can generate two key stress coping resources to help mitigate the negative effects of stress on mental health. First, these resources can foster friendships and social networks, providing valuable social support. Second, these resources can enhance a sense of autonomy, giving individuals a feeling of control over their actions. Studies have shown that participation in leisure activities in older adults is associated with a reduction in depressive symptoms as well as an increase in positive emotions [ 31 – 33 ]. Morse et al. also found that participating in outdoors activities, crafting, visiting friends and family, and swimming were associated with better mental health and fewer depressive symptoms in older adults [ 34 ]. Therefore, leisure activities may be a potential mediator of the association between physical disability and depressive symptoms in centenarians. 2.2 Attitudes toward aging (ATA) The condition of functional ability may create a negative attitude towards aging. Functional disability can be internalized, reinforcing a sense of helplessness and dependence in an individual’s identity [ 35 ]. Research has shown a positive correlation between physical function, measured by gait speed, chair-standing, and balance tests [ 36 ]. Another longitudinal study suggest that women with higher functional limitation have more negative view of aging (Longitudinal Predictors of Attitudes toward Aging among Women with Multiple Sclerosis). Studies have shown that a positive aging attitude is associated with lower levels of depression [ 37 , 38 ]. Those with a negative aging view are more likely to treat depressive symptoms as a normal part of aging, leading to the onset of pessimism and hindering treatment effectiveness [ 39 ]. Similarly, Quinn et al. found that negative attitudes toward aging are associated with negative perceptions of depression [ 40 ]. However, the mediating role of attitudes toward aging between functional disability and depressive symptoms in centenarians has not been fully explored. Thus, the objectives of this study are twofold. Research question 1: we aim to explore the association between functional disability and depressive symptoms among Chinese centenarians, we hypothesize functional disability is positively associated with depressive symptoms among Chinese centenarians. Research question 2: we aim to examine the mediating role of leisure activities and attitudes toward aging in this association, we hypothesize leisure activities play an indirect association between functional disability and depressive symptoms, and attitudes toward aging play an indirect association between functional disability and depressive symptoms. 3. Methods 3.1 Data source, procedure and participants Data were drawn from the 2018 Nanjing Centenarian Survey (NCS) (IRB-2017KYNCS001). This is a cross-sectional social survey jointly conducted by two universities, the survey is designed to explore how centenarians have developed their coping skills in daily life, the lifestyles they have adopted, and the impact of these factors on their quality of life. To achieve these goals, individuals aged 100 years or older were selected based on following inclusion criterias: (1) currently live in Nanjing city and (2) be aged 100 years old or older by April 30, 2018 based on household registration. Ultimately, 275 eligible participants were included. Attempts were made to recruit all living centenarians enrolled in the NCS by telephone. After consent was obtained, the research staff conducted face‒to‒face interviews. During the investigation period, 90 older adults did not complete the survey due to death (n = 19), migration or lost contact (n = 23), or refusal (n = 48). Our working sample included 185 participants. 3.2 Measurement 3.2.1 Dependent variable Depressive symptoms were measured using a 9 items subscale of the Center for Epidemiologic Studies Depression scale (CES-D) [ 41 , 42 ]. Participants were asked whether they had experienced the following nine feelings during the previous week: “I felt fearful”, “I felt lonely”, “I felt happy”, “I was bothered by things that usually do not bother me”, “I had trouble keeping my mind on what I was doing”, “I felt hopeful about the future”, “my sleep was restless”, “I felt depressed”, and “I could not get going”. We then coded how often each participant experienced each sensation as 1 (rarely or no time), 2 (part of the time), or 3 (most of the time). After reverse-coding the positive emotion items—“I felt happy” and “I felt hopeful about the future”, the scores for nine items were summed to produce an overall score for depressive symptoms ranging from 9 to 27, with higher scores indicating more severe depressive symptoms (Cronbach’s ɑ = 0.872). 3.2.2 Independent variables Functional disability was measured by self-reported ADL measures proposed by Katz et al. and IADL measures proposed by Lawton and Brody [ 43 , 44 ]. ADL consist of six basic personal activities of daily living (bathing, dressing, going to the toilet, indoor transferring, incontinence, and feeding), which are widely used to describe physical function in older adults. Respondents were asked whether they needed assistance in completing the above tasks (0 = need no assistance, 1 = need some assistance, and 2 = need complete assistance). Measurement of IADL were combined with items from major international surveys of older people [ 45 ]. Participants were asked whether they could complete seven tasks independently: cooking, washing, cleaning, walking 1 kilometer in a row, lifting 5 kilograms, squatting 3 times in a row, and taking public transport (0 = completely independently, 1 = needing some help, and 2 = unable). The ADL score ranges from 0–12, and the IADL score ranges from 0–14. The sum score of the ADL and IADL indicates the functional disability level of centenarians, and higher scores indicate severe functional disability. The Cronbach’s alpha for the functional disability was 0.942, indicating good internal consistency. 3.2.3 Mediators ATA were assessed using a 5 items subscale of the Philadelphia Geriatric Center Morale Scale (PCGMS) [ 46 ]. The items include: “As you get older you are less useful”, “Things keep worsening as I get older”, “I have much pep as I had last year”, “I am as happy now as when I was younger”, “As I get older, things are better than I thought they would be”. Each participant was asked to rate their agreement level with the statements on a 5-point Likert scale, from strongly disagree (1) to strongly agree (5), with items 3, 4 and 5 coded in reverse. The scores of the 5 items were then summed, with higher scores representing more negative attitudes. The Cronbach’s alpha for the ATA was 0.858 in this study. LA was assessed by a combined score for the frequency of 14 activities: doing housework, exercising, visiting parks, gardening, reading newspapers, playing cards, watching TV or listening to the radio, painting, listening to music, dancing, fishing, taking photos, talking to people, participating in social activities (1 = no participation, 2 = sometimes, 3 = at least once a month, 4 = at least once a week, and 5 = every day) [ 47 ]. Each centenarians’ level of leisure activity was obtained by adding together 14 scores and coding them in reverse. A higher score indicates a lower level of leisure activities. The Cronbach’s alpha for the LA measure was 0.708. 3.2.4 Covariates The sociodemographic variables in our study included age, gender, urban/rural residence, educational attainment, household income, number of children, living arrangements, chronic diseases and cognitive function. Chronic diseases condition was measured by a dichotomous variable that reflected whether participants had ever been told by a doctor that they had one or more of the following chronic conditions: hypertension, diabetes mellitus, heart disease, stroke, lung disease, cancer, or arthritis. Cognitive function adopted a validated Chinese version of the Mini-Mental State Examination (MMSE), which includes six domains (orientation, reaction, calculation, short-term memory, naming, and language) with a total score of 23, the higher score indicates the worse cognitive function. 3.2.5 Data analysis We employed three subsequent linear regression models and structural equation modelling (SEM) to examine the relationship between functional disability and depressive symptoms, and the mediating roles effects of LA and ATA. In Model 1, we added all of the control variables. In Model 2, we added functional disability based on Model 1. In Model 3, LA and ATA were further added. We then used SEM to test the pathways by which functional disability affects depressive symptoms in centenarians. 4. Results 4.1 Descriptive statistics Table 1 presents the characteristics of the overall sample of NCS participants. A total of 185 centenarians were included in this study. The mean depressive symptoms score was 23.6 (SD = 5.6). The functional disability averaged at 16.7 (SD = 7.5). The average ATA was 14.8 (SD = 4.0). The mean age was 102.0 years (SD = 2.1). The ratio of participants living with family members to those living with other was 3:1. Majority centenarians were urban residents (78.4%), more than half had no education (69.2%), were unmarried (96.2%), and had no chronic diseases (58.4%). Table 1 Descriptive characteristics of the study participants (N = 185) Characteristics N (%) Mean ± SD Depressive symptoms 23.6 ± 5.6 Functional disability 16.7 ± 7.5 Attitudes toward aging 14.8 ± 4.0 Leisure activities 64.2 ± 6.4 Age 102.0 ± 2.1 Sex Female 139 (75.1) Male 46 (24.9) Residence Rural 40 (21.6) Urban 145 (78.4) Education level 0 years of education 128 (69.2) 1 + years of education 57 (30.8) Annual household income 31459.8 ± 37164.2 Number of children 4.3 ± 2.4 Living arrangement Others 47 (25.4) Living with a spouse or family member 138 (74.6) Chronic diseases 0 chronic disease 108 (58.4) 1 + chronic diseases 77 (41.6) Cognitive function 9.45 ± 9.81 Note: SD: standard deviation. The added percentages may not be equal to 100% because of rounding. 4.2 Regression analysis The results of linear regression analysis are shown in Table 2 . We found that, after controlling all covariates, higher functional disability was associated with a higher level of depressive symptoms. Besides, when we contain mediators in the model, We found that centenarians with strong self-aging attitudes were more likely to be depressed, centenarians with less leisure activities were more likely to be depressed, while functional disability was not associated with depressive symptoms. Table 2 Linear regression results for depressive symptoms among centenarians Variables Model 1 Model 2 Model 3 Coefficient 95% CI Coefficient 95% CI Coefficient 95% CI Age -0.22 (-0.59, 0.15) -0.24 (-0.59, 0.11) -0.19 (-0.46,0.09) Male -0.87 (-2.72, 0.98) -0.85 (-2.62, 0.92) -0.55 (-1.94,0.83) Urban 0.70 (-1.19, 2.59) 0.86 (-0.95, 2.67) 2.09 ** (0.65, 3.53) 1 + years of schooling -0.11 (-1.90, 1.67) -0.51 (-2.23, 1.21) -0.43 (-1.80,0.94) Annual household income 0.25 (-0.07, 0.57) 0.15 (-0.16, 0.46) 0.27 * (0.02, 0.51) Number of children -0.26 (-0.59, 0.01) -0.32 * (-0.63,-0.01) -0.14 (-0.38,0.11) Living arrangement -0.84 (-2.57, 0.89) -0.19 (-1.87, 1.49) -0.51 (-1.82,0.81) Chronic diseases 0.15 (-1.41, 1.70) 0.10 (-1.38, 1.59) 0.49 (-0.68,1.66) Cognitive function -0.23 *** (-0.31,-0.16) -0.13 ** (-0.22,-0.05) -0.04 (-0.11,0.03) Functional disability 0.24 *** (0.12, 0.35) -0.01 (-0.11,0.09) Attitudes toward aging 0.85 *** (0.68, 1.02) Leisure activities 0.17 ** (0.06, 0.29) Number of obs 185 185 185 Constant 47.28 * 44.96 * 16.34 F value 5.17 6.79 18.68 R-squared 0.21 0.28 0.57 Adj squared 0.17 0.24 0.54 Note: ***p < 0.001; **p < 0.01; *p < 0.05 4.3 Path analysis We conducted path analysis to test the mediating role of LA and ATA in the association between functional disability and depressive symptoms. Specifically, we computed the total, direct, and indirect effects between variables, and controlled in the model for age, sex, urban/rural residence, years of education, annual household income, number of children, living arrangements, chronic diseases, and cognitive function. The results revealed that the total effect of functional disability on depressive symptoms was 0.237 (P < 0.001) (Fig. 1 ). As for LA, the direct effect of functional disability on depressive symptoms was 0.156 (P < 0.001) (Fig. 1 ), and the indirect effect of functional disability that passed through LA was 0.081 (P < 0.001). The proportion of the total effect that is possibly mediated by the effect of LA was 34.2%, suggesting a greater and significant partial mediating effect. We further conducted path analysis to test the mediating effect of ATA. The direct effect of functional disability on depressive symptoms was 0.041, indicating that the effect of functional disability on depressive symptoms was not significant. The indirect effect of functional disability that pass through ATA was 0.195 (P < 0.001). The proportion of the total effect mediated by ATA was 82.3%, indicating that ATA effect has a larger and more significant complete mediating effect. Note (1) The models controlled for age, sex, urban/rural residence, years of schooling, annual household income, number of children, living arrangements, chronic diseases status, and cognitive function. (2) ***p < 0.001, **p < 0.01, *p < 0.001. Note (1) The models controlled for age, sex, urban/rural residence, years of schooling, annual household income, number of children, living arrangements, chronic diseases status, and cognitive function. (2) ***p < 0.001, **p < 0.01, *p < 0.001. Table 3 Mediating effect analysis Effect Path relationships Indirect effect % of Indirect effect Indirect effect X→M1 (LA)→Y X→M2 (ATA)→Y 0.335*0.241 = 0.081 ** 0.222*0.880 = 0.195 ** 34.2% 82.3% Total indirect effect 0.081 + 0.195 = 0.276 ** Total effect 0.237 ** 5. Discussion This study is among the first to examine the relationships between functional disability, LA, ATA, and depressive symptoms in Chinese centenarians. Our findings suggest that greater functional disability is associated with more depressive symptoms, with leisure activities and attitudes toward aging mediating this relationship. Consistent with previous studies on older adults, we found a positive association between functional disability and depressive symptoms among centenarians. Although direct comparisons with prior studies are challenging due to the advanced age of our population, our findings support the link between functional disability and increased depressive symptoms in older adults [ 48 , 49 ]. This study extends the understanding that even at 100 years or older, greater functional ability is associated with better psychological well-being. We found that ATA fully mediate the association between physical disability and depressive symptoms in centenarians. This extends previous research [ 50 ], which demonstrated that negative ATA explains the association between functional disability and depressive symptoms. Consistent with the stress process theory, our findings highlight ATA as a key psychological resource in this association. Age-related changes, such as increased disabilities, can lower self-esteem and reinforce negative attitudes toward aging [ 51 ], which, in turn, worsen psychological status [ 37 ]. In our study, attitudes toward aging explained 82.3% of the association between functional disability and depressive symptoms, underscoring its critical role in the mental health of very old adults. We found that leisure activities significantly mediate in the association between functional disabilities and depressive symptoms, aligning with previous research [ 52 ]. For centenarians, functional disability is a major life stressor, and LA can help reduce this stress by promoting a positive self-image and self-efficacy [ 53 ]. They also support adaptive coping and provide crucial social resources like friendships and close relationships, which help alleviate negative emotions [ 54 , 55 ]. These connections can buffer against stress, improve attitudes toward aging, and lower depression risk [ 56 ]. Thus, government programs encouraging leisure activities among centenarians could significantly enhance psychological well-being.. 5.1 Study limitations This study has several limitations. First, as a cross-sectional study, it cannot determine causality between functional disability and depressive symptoms. Second, the leisure activity data, being self-reported or reported by family, may subject to measurement error. Third, the sample was limited to centenarians in Nanjing, which may restrict the generalizability of the findings to other regions in China. Forth, since many centenarians have not seen a physician for a long time, the number of centenarians with chronic diseases need further verification. 5.2 Conclusion The findings of this study suggest that functional disability, ATA, and LA are significantly associated with depressive symptoms in Chinese centenarians. It is crucial to Implement programs that promote positive ATA and increase access to LA to help reduce the risk of depression in this population. Abbreviations ADLs Activities of Daily Living IADLs Instrumental Activities of Daily Living NCS Nanjing Centenarians Survey CES-D Center for Epidemiological Studies Depression Scale ATA Attitudes Toward Aging LA Leisure Activities PGCMS Philadelphia Geriatric Center Morale Scale MMSE Mini-Mental State Examination SE Standard Error SD Standard Deviation Coef Coefficient CI Confidence Interval Declarations Competing interests Not applicable. Ethical approval Not applicable. Clinical trial number Not applicable. Disclaimer The views expressed in the article are solely those of the authors and do not reflect those of the Nanjing University of Posts and Telecommunications, The University of Texas at Austin, New York University, Nanjing Normal University, or the Jiangsu Center for Collaborative Innovation in Geographical Information Resource Development and Application. Funding The work was supported by the Jiangsu Social Science Foundation Project (Item number: 22SHC006). Author Contribution X.X. formulated the research and developed the primary framework of the study; Y, P., B.W., and Y.Z. revised and edited the manuscript; B.W. and Y.Z. contributed to the final manuscript. The final manuscript submitted for publication was read and approved by X.X., Y, P., B.W., and Y.Z. All authors have read and agreed to the published version of the manuscript. Availability of data and materials declarations References Leung Y, Barzilai N, Batko-Szwaczka A et al (2022) Cognition, function, and prevalent dementia in centenarians and near-centenarians: An individual participant data (IPD) meta-analysis of 18 studies. Alzheimer’s Dement 19:2265–2275. https://doi.org/10.1002/alz.12828 Enroth L, Raitanen J, Halonen P et al (2020) Trends of physical functioning, morbidity and disability-free life expectancy among the oldest old: Six repeated cross-sectional surveys between 2001 and 2018 in the Vitality 90 + Study. The Journals of Gerontology. 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Front Psychol 12:609967. https://doi.org/10.3389/fpsyg.2021.609967 Zola IK (1993) Self, identity and the naming question: Reflections on the language of disability. Soc Sci Med 36:167–173. https://doi.org/10.1016/0277-9536(93)90208-L Franchignoni F, Giordano A, Rinaldo L et al (2022) Assessing individual-level measurement precision of the Short Physical Performance Battery using the test information function. Int J Rehabilitation Res Int Z Fur Rehabilitationsforschung Revue Int de Recherches de Readaptation 46:46–52. https://doi.org/10.1097/MRR.0000000000000557 Rackoff G, Newman M (2020) Reduced positive affect on days with stress exposure predicts depression, anxiety disorders, and low trait positive affect 7 years later. J Abnorm Psychol 129(8):799–809. https://doi.org/10.1037/abn0000639 Chachamovich E, Fleck M, Laidlaw K et al (2008) Impact of major depression and subsyndromal symptoms on quality of life and attitudes toward aging in an international sample of older adults. Gerontologist 485:593–602. https://doi.org/10.1093/GERONT/48.5.593 Law J, Laidlaw K, Peck D (2010) Is depression viewed as an inevitable Consequence of age? The Understandability Phenomenon in older people. Clin Gerontologist 33:194–209. https://doi.org/10.1080/07317111003773627 Quinn KM, Laidlaw K, Murray L (2009) Older peoples’ attitudes to mental illness. Clin Psychol Psychother 161:33–45. https://doi.org/10.1002/cpp.598 Radloff L, The CES-D, Scale (1977) A self-report depression scale for research in the general population. Appl Psychol Meas 1(3):385–401. https://doi.org/10.1177/014662167700100306 Andresen E, Malmgren J, Carter WB et al (1994) Screening for depression in well older adults: evaluation of a short form of the CES-D (Center for Epidemiologic Studies Depression Scale). Am J Prev Med 102:77–84. https://doi.org/10.1016/S0749-3797(18)30622-6 Katz S, Ford A, Moskowitz R et al (1963) Studies of illness in the aged. JAMA 185:914–919. https://doi.org/10.1001/jama.1963.03060120024016 Lawton M, Brody E (1969) Assessment of older people: Self-maintaining and instrumental activities of daily living. Gerontologist 9:179–186. https://doi.org/10.1111/j.1532-5415.1983.tb03391.x Gu D (2008) General data quality assessment of the CLHLS. In: Yi Z, Poston DL, Vlosky DA, Gu D (eds) Healthy longevity in China: Demographic, socioeconomic, and psychological dimensions. Springer Netherlands, Dordrecht, The Netherlands, pp 39–60 Lawton M (1975) The Philadelphia Geriatric Center Morale Scale: A revision. J Gerontol 30:85–89. https://doi.org/10.1093/GERONJ/30.1.85 Xu X, Zhao Y, Xia S et al (2020) Quality of life and its influencing factors among centenarians in Nanjing, China: A cross-sectional study. Soc Indic Res 160:735–755. https://doi.org/10.1007/s11205-020-02399-4 Kim K, Hwang G, Cho Y et al (2022) Relationships of physical activity, depression, and sleep with cognitive function in community-dwelling older adults. Int J Environ Res Public Health 19(23):15655. https://doi.org/10.3390/ijerph192315655 Yan Y, Du Y, Li X et al (2023) Physical function, ADL, and depressive symptoms in Chinese elderly: Evidence from the CHARLS. Front Public Health 11:1017689. https://doi.org/10.3389/fpubh.2023.1017689 Bryant C, Bei B, Gilson K et al (2012) The relationship between attitudes to aging and physical and mental health in older adults. Int Psychogeriatr 24:1674–1683. https://doi.org/10.1017/S1041610212000774 Wang G, Shi J, Yao J et al (2019) Relationship between activities of daily living and attitude toward own aging among the elderly in China: A chain mediating model. Int J Aging Hum Dev 91(4):581–598. https://doi.org/10.1177/0091415019864595 Holt-Lunstad J, Smith T, Baker M et al (2015) Loneliness and social isolation as risk factors for mortality: A meta-analytic review. Perspect Psychol Sci 10:227–237. https://doi.org/10.1177/1745691614568352 Gyasi R, Phillips D, Abass K (2018) Social support networks and psychological wellbeing in community-dwelling older Ghanaian cohorts. Int Psychogeriatr 31:1–11. https://doi.org/10.1017/S1041610218001539 Muramatsu N, Yin H, Hedeker D (2010) Functional declines, social support, and mental health in the elderly: Does living in a state supportive of home and community-based services make a difference? Soc Sci Med 70:1050–1058. https://doi.org/10.1016/j.socscimed.2009.12.005 Tsai A, Papachristos A (2015) From social integration to health: Durkheim after the turn of the millennium. Soc Sci Med 125:1–7. https://doi.org/10.1016/J.SOCSCIMED.2014.10.045 Hakulinen C, Laura P, Jokela M et al (2016) Structural and functional aspects of social support as predictors of mental and physical health trajectories: Whitehall II cohort study. J Epidemiol Commun Health 70:710–715. https://doi.org/10.1136/jech-2015-206165 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted 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-5307508","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":369353696,"identity":"f8886f59-b10e-4acc-8f42-1d0614015f4b","order_by":0,"name":"Xin Xu","email":"","orcid":"","institution":"Nanjing University of Posts and Telecommunications","correspondingAuthor":false,"prefix":"","firstName":"Xin","middleName":"","lastName":"Xu","suffix":""},{"id":369353697,"identity":"9dac19b6-f951-4d04-916c-db0acd6bd206","order_by":1,"name":"Yaolin Pei","email":"","orcid":"","institution":"The University of Texas at Austin","correspondingAuthor":false,"prefix":"","firstName":"Yaolin","middleName":"","lastName":"Pei","suffix":""},{"id":369353698,"identity":"e441095b-cea1-4b48-9a34-01bc7099efe5","order_by":2,"name":"Bei Wu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAq0lEQVRIiWNgGAWjYBACAwbGBiBlA+HxkKAljSQtYHCYBC3m7M0NzLxt5/MMbiQwPnjbRoQWy56DIC23i4FamA3nEqPF4EZiA3Nu2+3EDTcS2KR5idJy/yFIyzmQFvbfxGm5wQjScgBsCzNRWix7EhsO/zmXnDjzzMNmyTnniNBizn784cMZZXaJfceTD354U0aEFhA4ACIUDoDjlBQgT6qGUTAKRsEoGDkAADYoOsTh7paSAAAAAElFTkSuQmCC","orcid":"","institution":"New York University","correspondingAuthor":true,"prefix":"","firstName":"Bei","middleName":"","lastName":"Wu","suffix":""},{"id":369353699,"identity":"a4fe9a9e-4d21-4719-97fd-8e75c4db3c80","order_by":3,"name":"Yuan Zhao","email":"","orcid":"","institution":"Nanjing Normal University","correspondingAuthor":false,"prefix":"","firstName":"Yuan","middleName":"","lastName":"Zhao","suffix":""}],"badges":[],"createdAt":"2024-10-22 01:38:14","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5307508/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5307508/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":68291968,"identity":"02f72b8d-9840-48e6-baf5-19897874b73b","added_by":"auto","created_at":"2024-11-05 17:26:58","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":36750,"visible":true,"origin":"","legend":"\u003cp\u003eMediating effect of leisure activities on the relationship between functional disability and depressive symptoms.\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-5307508/v1/2d143d47712881fc88729dea.jpeg"},{"id":68291967,"identity":"07d89c0d-4077-4465-99f6-162c68f66638","added_by":"auto","created_at":"2024-11-05 17:26:58","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":49334,"visible":true,"origin":"","legend":"\u003cp\u003eMediating effect of attitudes toward aging in the relationship between functional disability and depressive symptoms.\u003c/p\u003e","description":"","filename":"Onlinefloatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-5307508/v1/fb5c91f62d89cf68533c0454.png"},{"id":69537753,"identity":"3a69ba49-43f5-4b16-9d21-e37d1b35d93a","added_by":"auto","created_at":"2024-11-21 12:08:57","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":775485,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5307508/v1/61cb3d85-d94d-4eec-861b-94f09ef0e129.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Functional disability and depressive symptoms among centenarians in Nanjing, China: The mediating role of leisure activities and attitudes toward aging","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eWith rising living standard, lifestyle changes, and medical advancements, more people around the world are living exceptionally long life. In China, the number of centenarians reached 118,900 at the end of 2020, a 3.3-fold times from 2010. Centenarians are often seen as models of successful aging due to their remarkable longevity, but they exhibit significant variations in functional and cognitive abilities [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. For many centenarians, extended life expectancy is often accompanied by increased morbidity and decreased functionality [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. These declines impact not only survival, but also key aspects of quality of life, including independent living and overall well-being [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDepression is a significant contributor to the global burden of disease [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Despite ample evidence linking functional disability and depressive symptoms [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], few studies have explored whether this association exists in extremely old ages. Physical function declines with age. Indeed, centenarians often experience severe physical health challenges. For example, in a Japanese centenarian sample, approximately one-third of the centenarians were totally physically dependent, and a quarter of them functioned independently [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. The Second Heidelberg Centenarian Study showed that the average physical activities of daily living (PADL) and instrumental activities of daily living (IADL) scores of centenarians were at a low to medium level [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Besides, studies have also shown that functional disability may be a risk factor for depressive symptoms, and its possible mechanisms reveal that functional disability as a stressful event increases the likelihood of developing depressive symptoms. However, whether functional disability is associated with the onset of depressive symptoms among centenarians deserves further investigation.\u003c/p\u003e \u003cp\u003eLeisure activities and the way older adults perceive their aging process have been suggested to have great implications for their psychological well-being. Using a sample of centenarians collected in Nanjing, the aims of this study are: (1) What is the relationship between functional disability and depressive symptoms in centenarians? (2) what are the factors that mediate the association between functional disability and depressive symptoms? In this study, we aim to specifically explore how functional disability is associated with the emergence of depressive symptoms through leisure activities and attitudes toward aging. Based on the stress process theory, we posit that functional disability is a chronic stress that disrupts engagement in leisure activities, and positive attitudes toward aging, which in turn, amplify depressive symptoms.\u003c/p\u003e"},{"header":"2. Functional disability, leisure activities, attitudes toward aging, and depressive symptoms","content":"\u003cp\u003eFunctional disability refers to the acquired difficulties that older adults have in performing basic and complex tasks required for daily living [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], including challenges in basic activities of daily living (ADL) and instrumental activities of daily living (IADL) [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Functional disability has long been recognized as a significant stressor contributing to unhappiness and depression in later life [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. A substantial body of studies provide strong evidence that physical dysfunction is associated with increased depressive symptoms in old age [\u003cspan additionalcitationids=\"CR14 CR15\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. On the one hand, inability to perform daily activities triggers feelings of incompetence and dependence, leading to distress and pessimism [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. In contrary, chronic depression reduces leisure activities participation [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], limits interpersonal interactions [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], and impairs cognitive function [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e], and further hinder the ability to conduct ADL and IADL independently. While the relationship between functional disability and depressive symptoms is well-documented, there remains a need to better understand how functional disability specifically affects depressive symptoms among centenarians.\u003c/p\u003e \u003cp\u003eThe Stress Process Theory is a theoretical framework for explaining and analyzing how individuals experience, cope with, and adapt to life stress [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. It focuses on how stressor, such as functional disability, affect individuals\u0026rsquo; mental health through some resources (behavioral responses and long-term psycho-social adaptation) [\u003cspan additionalcitationids=\"CR23 CR24\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. However, there is limited understanding of the role that these resources, such as leisure activities and attitudes toward aging, play in the association between functional disability and depressive symptoms.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Leisure activities (LA)\u003c/h2\u003e \u003cp\u003eLeisure activities are defined as participation in activities that promote interaction with others in society or the community [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Older adults\u0026rsquo; leisure activities is greatly affected by their functional health status. Both cross-sectional and longitudinal studies have found that age-related functional decline not only reduces the frequency of leisure activities [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e], but also limits the types of activities that individuals can engage in, such as sports and housework [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. A British study also found that older adults are more likely to meet moderate or vigorous leisure activity guidelines if they do not have chronic health problems and severe mobility impairments [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eLeisure activities can generate two key stress coping resources to help mitigate the negative effects of stress on mental health. First, these resources can foster friendships and social networks, providing valuable social support. Second, these resources can enhance a sense of autonomy, giving individuals a feeling of control over their actions. Studies have shown that participation in leisure activities in older adults is associated with a reduction in depressive symptoms as well as an increase in positive emotions [\u003cspan additionalcitationids=\"CR32\" citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Morse et al. also found that participating in outdoors activities, crafting, visiting friends and family, and swimming were associated with better mental health and fewer depressive symptoms in older adults [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Therefore, leisure activities may be a potential mediator of the association between physical disability and depressive symptoms in centenarians.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Attitudes toward aging (ATA)\u003c/h2\u003e \u003cp\u003eThe condition of functional ability may create a negative attitude towards aging. Functional disability can be internalized, reinforcing a sense of helplessness and dependence in an individual\u0026rsquo;s identity [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Research has shown a positive correlation between physical function, measured by gait speed, chair-standing, and balance tests [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Another longitudinal study suggest that women with higher functional limitation have more negative view of aging (Longitudinal Predictors of Attitudes toward Aging among Women with Multiple Sclerosis).\u003c/p\u003e \u003cp\u003eStudies have shown that a positive aging attitude is associated with lower levels of depression [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Those with a negative aging view are more likely to treat depressive symptoms as a normal part of aging, leading to the onset of pessimism and hindering treatment effectiveness [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Similarly, Quinn et al. found that negative attitudes toward aging are associated with negative perceptions of depression [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. However, the mediating role of attitudes toward aging between functional disability and depressive symptoms in centenarians has not been fully explored.\u003c/p\u003e \u003cp\u003eThus, the objectives of this study are twofold. Research question 1: we aim to explore the association between functional disability and depressive symptoms among Chinese centenarians, we hypothesize functional disability is positively associated with depressive symptoms among Chinese centenarians. Research question 2: we aim to examine the mediating role of leisure activities and attitudes toward aging in this association, we hypothesize leisure activities play an indirect association between functional disability and depressive symptoms, and attitudes toward aging play an indirect association between functional disability and depressive symptoms.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Methods","content":"\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Data source, procedure and participants\u003c/h2\u003e \u003cp\u003eData were drawn from the 2018 Nanjing Centenarian Survey (NCS) (IRB-2017KYNCS001). This is a cross-sectional social survey jointly conducted by two universities, the survey is designed to explore how centenarians have developed their coping skills in daily life, the lifestyles they have adopted, and the impact of these factors on their quality of life. To achieve these goals, individuals aged 100 years or older were selected based on following inclusion criterias: (1) currently live in Nanjing city and (2) be aged 100 years old or older by April 30, 2018 based on household registration. Ultimately, 275 eligible participants were included. Attempts were made to recruit all living centenarians enrolled in the NCS by telephone. After consent was obtained, the research staff conducted face‒to‒face interviews. During the investigation period, 90 older adults did not complete the survey due to death (n\u0026thinsp;=\u0026thinsp;19), migration or lost contact (n\u0026thinsp;=\u0026thinsp;23), or refusal (n\u0026thinsp;=\u0026thinsp;48). Our working sample included 185 participants.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Measurement\u003c/h2\u003e \u003cdiv id=\"Sec8\" class=\"Section3\"\u003e \u003ch2\u003e3.2.1 Dependent variable\u003c/h2\u003e \u003cp\u003eDepressive symptoms were measured using a 9 items subscale of the Center for Epidemiologic Studies Depression scale (CES-D) [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. Participants were asked whether they had experienced the following nine feelings during the previous week: \u0026ldquo;I felt fearful\u0026rdquo;, \u0026ldquo;I felt lonely\u0026rdquo;, \u0026ldquo;I felt happy\u0026rdquo;, \u0026ldquo;I was bothered by things that usually do not bother me\u0026rdquo;, \u0026ldquo;I had trouble keeping my mind on what I was doing\u0026rdquo;, \u0026ldquo;I felt hopeful about the future\u0026rdquo;, \u0026ldquo;my sleep was restless\u0026rdquo;, \u0026ldquo;I felt depressed\u0026rdquo;, and \u0026ldquo;I could not get going\u0026rdquo;. We then coded how often each participant experienced each sensation as 1 (rarely or no time), 2 (part of the time), or 3 (most of the time). After reverse-coding the positive emotion items\u0026mdash;\u0026ldquo;I felt happy\u0026rdquo; and \u0026ldquo;I felt hopeful about the future\u0026rdquo;, the scores for nine items were summed to produce an overall score for depressive symptoms ranging from 9 to 27, with higher scores indicating more severe depressive symptoms (Cronbach\u0026rsquo;s ɑ = 0.872).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section3\"\u003e \u003ch2\u003e3.2.2 Independent variables\u003c/h2\u003e \u003cp\u003eFunctional disability was measured by self-reported ADL measures proposed by Katz et al. and IADL measures proposed by Lawton and Brody [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. ADL consist of six basic personal activities of daily living (bathing, dressing, going to the toilet, indoor transferring, incontinence, and feeding), which are widely used to describe physical function in older adults. Respondents were asked whether they needed assistance in completing the above tasks (0\u0026thinsp;=\u0026thinsp;need no assistance, 1\u0026thinsp;=\u0026thinsp;need some assistance, and 2\u0026thinsp;=\u0026thinsp;need complete assistance). Measurement of IADL were combined with items from major international surveys of older people [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. Participants were asked whether they could complete seven tasks independently: cooking, washing, cleaning, walking 1 kilometer in a row, lifting 5 kilograms, squatting 3 times in a row, and taking public transport (0\u0026thinsp;=\u0026thinsp;completely independently, 1\u0026thinsp;=\u0026thinsp;needing some help, and 2\u0026thinsp;=\u0026thinsp;unable). The ADL score ranges from 0\u0026ndash;12, and the IADL score ranges from 0\u0026ndash;14. The sum score of the ADL and IADL indicates the functional disability level of centenarians, and higher scores indicate severe functional disability. The Cronbach\u0026rsquo;s alpha for the functional disability was 0.942, indicating good internal consistency.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section3\"\u003e \u003ch2\u003e3.2.3 Mediators\u003c/h2\u003e \u003cp\u003eATA were assessed using a 5 items subscale of the Philadelphia Geriatric Center Morale Scale (PCGMS) [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. The items include: \u0026ldquo;As you get older you are less useful\u0026rdquo;, \u0026ldquo;Things keep worsening as I get older\u0026rdquo;, \u0026ldquo;I have much pep as I had last year\u0026rdquo;, \u0026ldquo;I am as happy now as when I was younger\u0026rdquo;, \u0026ldquo;As I get older, things are better than I thought they would be\u0026rdquo;. Each participant was asked to rate their agreement level with the statements on a 5-point Likert scale, from strongly disagree (1) to strongly agree (5), with items 3, 4 and 5 coded in reverse. The scores of the 5 items were then summed, with higher scores representing more negative attitudes. The Cronbach\u0026rsquo;s alpha for the ATA was 0.858 in this study.\u003c/p\u003e \u003cp\u003eLA was assessed by a combined score for the frequency of 14 activities: doing housework, exercising, visiting parks, gardening, reading newspapers, playing cards, watching TV or listening to the radio, painting, listening to music, dancing, fishing, taking photos, talking to people, participating in social activities (1\u0026thinsp;=\u0026thinsp;no participation, 2\u0026thinsp;=\u0026thinsp;sometimes, 3\u0026thinsp;=\u0026thinsp;at least once a month, 4\u0026thinsp;=\u0026thinsp;at least once a week, and 5\u0026thinsp;=\u0026thinsp;every day) [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. Each centenarians\u0026rsquo; level of leisure activity was obtained by adding together 14 scores and coding them in reverse. A higher score indicates a lower level of leisure activities. The Cronbach\u0026rsquo;s alpha for the LA measure was 0.708.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section3\"\u003e \u003ch2\u003e3.2.4 Covariates\u003c/h2\u003e \u003cp\u003eThe sociodemographic variables in our study included age, gender, urban/rural residence, educational attainment, household income, number of children, living arrangements, chronic diseases and cognitive function. Chronic diseases condition was measured by a dichotomous variable that reflected whether participants had ever been told by a doctor that they had one or more of the following chronic conditions: hypertension, diabetes mellitus, heart disease, stroke, lung disease, cancer, or arthritis. Cognitive function adopted a validated Chinese version of the Mini-Mental State Examination (MMSE), which includes six domains (orientation, reaction, calculation, short-term memory, naming, and language) with a total score of 23, the higher score indicates the worse cognitive function.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section3\"\u003e \u003ch2\u003e3.2.5 Data analysis\u003c/h2\u003e \u003cp\u003eWe employed three subsequent linear regression models and structural equation modelling (SEM) to examine the relationship between functional disability and depressive symptoms, and the mediating roles effects of LA and ATA. In Model 1, we added all of the control variables. In Model 2, we added functional disability based on Model 1. In Model 3, LA and ATA were further added. We then used SEM to test the pathways by which functional disability affects depressive symptoms in centenarians.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"4. Results","content":"\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e4.1 Descriptive statistics\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e presents the characteristics of the overall sample of NCS participants. A total of 185 centenarians were included in this study. The mean depressive symptoms score was 23.6 (SD\u0026thinsp;=\u0026thinsp;5.6). The functional disability averaged at 16.7 (SD\u0026thinsp;=\u0026thinsp;7.5). The average ATA was 14.8 (SD\u0026thinsp;=\u0026thinsp;4.0). The mean age was 102.0 years (SD\u0026thinsp;=\u0026thinsp;2.1). The ratio of participants living with family members to those living with other was 3:1. Majority centenarians were urban residents (78.4%), more than half had no education (69.2%), were unmarried (96.2%), and had no chronic diseases (58.4%).\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\u003eDescriptive characteristics of the study participants (N\u0026thinsp;=\u0026thinsp;185)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\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=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDepressive symptoms\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e23.6\u0026thinsp;\u0026plusmn;\u0026thinsp;5.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFunctional disability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e16.7\u0026thinsp;\u0026plusmn;\u0026thinsp;7.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAttitudes toward aging\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e14.8\u0026thinsp;\u0026plusmn;\u0026thinsp;4.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeisure activities\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e64.2\u0026thinsp;\u0026plusmn;\u0026thinsp;6.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e102.0\u0026thinsp;\u0026plusmn;\u0026thinsp;2.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\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 \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e139 (75.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\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=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e46 (24.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResidence\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 \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e40 (21.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e145 (78.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducation level\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 \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0 years of education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e128 (69.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u0026thinsp;+\u0026thinsp;years of education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e57 (30.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnnual household income\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e31459.8\u0026thinsp;\u0026plusmn;\u0026thinsp;37164.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of children\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e4.3\u0026thinsp;\u0026plusmn;\u0026thinsp;2.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLiving arrangement\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 \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e47 (25.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLiving with a spouse or family member\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e138 (74.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChronic diseases\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 \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0 chronic disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e108 (58.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u0026thinsp;+\u0026thinsp;chronic diseases\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e77 (41.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCognitive function\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e9.45\u0026thinsp;\u0026plusmn;\u0026thinsp;9.81\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003eNote: SD: standard deviation. The added percentages may not be equal to 100% because of rounding.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003e4.2 Regression analysis\u003c/h2\u003e \u003cp\u003eThe results of linear regression analysis are shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. We found that, after controlling all covariates, higher functional disability was associated with a higher level of depressive symptoms. Besides, when we contain mediators in the model, We found that centenarians with strong self-aging attitudes were more likely to be depressed, centenarians with less leisure activities were more likely to be depressed, while functional disability was not associated with depressive symptoms.\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\u003eLinear regression results for depressive symptoms among centenarians\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\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 \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eModel 1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eModel 2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eModel 3\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCoefficient\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCoefficient\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eCoefficient\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(-0.59, 0.15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(-0.59, 0.11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-0.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e(-0.46,0.09)\u003c/p\u003e \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\u003e-0.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(-2.72, 0.98)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(-2.62, 0.92)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-0.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e(-1.94,0.83)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(-1.19, 2.59)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(-0.95, 2.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.09\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e(0.65, 3.53)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u0026thinsp;+\u0026thinsp;years of schooling\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(-1.90, 1.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(-2.23, 1.21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-0.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e(-1.80,0.94)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnnual household income\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(-0.07, 0.57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(-0.16, 0.46)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.27\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e(0.02, 0.51)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of children\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(-0.59, 0.01)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.32\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(-0.63,-0.01)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-0.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e(-0.38,0.11)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLiving arrangement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(-2.57, 0.89)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(-1.87, 1.49)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-0.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e(-1.82,0.81)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChronic diseases\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(-1.41, 1.70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(-1.38, 1.59)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e(-0.68,1.66)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCognitive function\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.23\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(-0.31,-0.16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.13\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(-0.22,-0.05)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-0.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e(-0.11,0.03)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFunctional disability\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 \u003cp\u003e0.24\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(0.12, 0.35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e(-0.11,0.09)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAttitudes toward aging\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 \u003cp\u003e0.85\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e(0.68, 1.02)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeisure activities\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 \u003cp\u003e0.17\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e(0.06, 0.29)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of obs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e185\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e185\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e185\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConstant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e47.28\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e44.96\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e16.34\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eF value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e5.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e6.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e18.68\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eR-squared\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e0.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e0.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e0.57\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdj squared\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e0.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e0.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e0.54\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003eNote: ***p\u0026thinsp;\u0026lt;\u0026thinsp;0.001; **p\u0026thinsp;\u0026lt;\u0026thinsp;0.01; *p\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003e4.3 Path analysis\u003c/h2\u003e \u003cp\u003eWe conducted path analysis to test the mediating role of LA and ATA in the association between functional disability and depressive symptoms. Specifically, we computed the total, direct, and indirect effects between variables, and controlled in the model for age, sex, urban/rural residence, years of education, annual household income, number of children, living arrangements, chronic diseases, and cognitive function. The results revealed that the total effect of functional disability on depressive symptoms was 0.237 (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e1\u003c/span\u003e). As for LA, the direct effect of functional disability on depressive symptoms was 0.156 (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e1\u003c/span\u003e), and the indirect effect of functional disability that passed through LA was 0.081 (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The proportion of the total effect that is possibly mediated by the effect of LA was 34.2%, suggesting a greater and significant partial mediating effect.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eWe further conducted path analysis to test the mediating effect of ATA. The direct effect of functional disability on depressive symptoms was 0.041, indicating that the effect of functional disability on depressive symptoms was not significant. The indirect effect of functional disability that pass through ATA was 0.195 (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The proportion of the total effect mediated by ATA was 82.3%, indicating that ATA effect has a larger and more significant complete mediating effect.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eNote\u003c/strong\u003e \u003cp\u003e(1) The models controlled for age, sex, urban/rural residence, years of schooling, annual household income, number of children, living arrangements, chronic diseases status, and cognitive function. (2) ***p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, **p\u0026thinsp;\u0026lt;\u0026thinsp;0.01, *p\u0026thinsp;\u0026lt;\u0026thinsp;0.001.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eNote\u003c/strong\u003e \u003cp\u003e(1) The models controlled for age, sex, urban/rural residence, years of schooling, annual household income, number of children, living arrangements, chronic diseases status, and cognitive function. (2) ***p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, **p\u0026thinsp;\u0026lt;\u0026thinsp;0.01, *p\u0026thinsp;\u0026lt;\u0026thinsp;0.001.\u003c/p\u003e \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\u003eMediating effect analysis\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\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 \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEffect\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePath relationships\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIndirect effect\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e% of Indirect effect\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndirect effect\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eX\u0026rarr;M1 (LA)\u0026rarr;Y\u003c/p\u003e \u003cp\u003eX\u0026rarr;M2 (ATA)\u0026rarr;Y\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.335*0.241\u0026thinsp;=\u0026thinsp;0.081\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e0.222*0.880\u0026thinsp;=\u0026thinsp;0.195\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e34.2%\u003c/p\u003e \u003cp\u003e82.3%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal indirect effect\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.081\u0026thinsp;+\u0026thinsp;0.195\u0026thinsp;=\u0026thinsp;0.276\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal effect\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.237\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\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"},{"header":"5. Discussion","content":"\u003cp\u003eThis study is among the first to examine the relationships between functional disability, LA, ATA, and depressive symptoms in Chinese centenarians. Our findings suggest that greater functional disability is associated with more depressive symptoms, with leisure activities and attitudes toward aging mediating this relationship.\u003c/p\u003e \u003cp\u003eConsistent with previous studies on older adults, we found a positive association between functional disability and depressive symptoms among centenarians. Although direct comparisons with prior studies are challenging due to the advanced age of our population, our findings support the link between functional disability and increased depressive symptoms in older adults [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]. This study extends the understanding that even at 100 years or older, greater functional ability is associated with better psychological well-being.\u003c/p\u003e \u003cp\u003eWe found that ATA fully mediate the association between physical disability and depressive symptoms in centenarians. This extends previous research [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e], which demonstrated that negative ATA explains the association between functional disability and depressive symptoms. Consistent with the stress process theory, our findings highlight ATA as a key psychological resource in this association. Age-related changes, such as increased disabilities, can lower self-esteem and reinforce negative attitudes toward aging [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e], which, in turn, worsen psychological status [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. In our study, attitudes toward aging explained 82.3% of the association between functional disability and depressive symptoms, underscoring its critical role in the mental health of very old adults.\u003c/p\u003e \u003cp\u003eWe found that leisure activities significantly mediate in the association between functional disabilities and depressive symptoms, aligning with previous research [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e]. For centenarians, functional disability is a major life stressor, and LA can help reduce this stress by promoting a positive self-image and self-efficacy [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e]. They also support adaptive coping and provide crucial social resources like friendships and close relationships, which help alleviate negative emotions [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e, \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e]. These connections can buffer against stress, improve attitudes toward aging, and lower depression risk [\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e]. Thus, government programs encouraging leisure activities among centenarians could significantly enhance psychological well-being..\u003c/p\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003e5.1 Study limitations\u003c/h2\u003e \u003cp\u003eThis study has several limitations. First, as a cross-sectional study, it cannot determine causality between functional disability and depressive symptoms. Second, the leisure activity data, being self-reported or reported by family, may subject to measurement error. Third, the sample was limited to centenarians in Nanjing, which may restrict the generalizability of the findings to other regions in China. Forth, since many centenarians have not seen a physician for a long time, the number of centenarians with chronic diseases need further verification.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003e5.2 Conclusion\u003c/h2\u003e \u003cp\u003eThe findings of this study suggest that functional disability, ATA, and LA are significantly associated with depressive symptoms in Chinese centenarians. It is crucial to Implement programs that promote positive ATA and increase access to LA to help reduce the risk of depression in this population.\u003c/p\u003e \u003c/div\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eADLs\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eActivities of Daily Living\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIADLs\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eInstrumental Activities of Daily Living\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNCS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNanjing Centenarians Survey\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCES-D\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCenter for Epidemiological Studies Depression Scale\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eATA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAttitudes Toward Aging\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eLeisure Activities\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePGCMS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePhiladelphia Geriatric Center Morale Scale\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMMSE\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMini-Mental State Examination\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSE\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eStandard Error\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eStandard Deviation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCoef\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCoefficient\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eConfidence Interval\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003ch2\u003eCompeting interests\u003c/h2\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003ch2\u003eClinical trial number\u003c/h2\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003ch2\u003eDisclaimer\u003c/h2\u003e\n\u003cp\u003eThe views expressed in the article are solely those of the authors and do not reflect those of the Nanjing University of Posts and Telecommunications, The University of Texas at Austin, New York University, Nanjing Normal University, or the Jiangsu Center for Collaborative Innovation in Geographical Information Resource Development and Application.\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eThe work was supported by the Jiangsu Social Science Foundation Project (Item number: 22SHC006).\u003c/p\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\n\u003cp\u003eX.X. formulated the research and developed the primary framework of the study; Y, P., B.W., and Y.Z. revised and edited the manuscript; B.W. and Y.Z. contributed to the final manuscript. The final manuscript submitted for publication was read and approved by X.X., Y, P., B.W., and Y.Z. All authors have read and agreed to the published version of the manuscript.\u003c/p\u003e\n\u003ch2\u003eAvailability of data and materials\u003c/h2\u003e\n\u003cp\u003edeclarations\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eLeung Y, Barzilai N, Batko-Szwaczka A et al (2022) Cognition, function, and prevalent dementia in centenarians and near-centenarians: An individual participant data (IPD) meta-analysis of 18 studies. 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J Epidemiol Commun Health 70:710\u0026ndash;715. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1136/jech-2015-206165\u003c/span\u003e\u003cspan address=\"10.1136/jech-2015-206165\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"functional disability, depressive symptoms, leisure activities, attitudes toward aging, centenarian","lastPublishedDoi":"10.21203/rs.3.rs-5307508/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5307508/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eObjective\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThis study examines the association between functional disability and depressive symptoms among Chinese centenarians, and the mediating role of leisure activities and attitudes toward aging in this association.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThe data were obtained from a cross-sectional household survey of 185 centenarians in Nanjing. We used OLS and structural equation modeling to examine the associations between functional disability, leisure activities, attitudes toward aging, and depressive symptoms.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e \u003cp\u003eFunctional disability was positively associated with depressive symptoms (b\u0026thinsp;=\u0026thinsp;0.24, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Both leisure activities (34.2%) and attitudes toward aging (82.3%) partially mediated the association between functional disability and depressive symptoms among centenarians.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusions\u003c/b\u003e\u003c/p\u003e \u003cp\u003eOur findings suggest that engaging in leisure activities and fostering a positive attitude toward aging may help very old adults maintain their mental well-being, despite declines in physical functioning.\u003c/p\u003e","manuscriptTitle":"Functional disability and depressive symptoms among centenarians in Nanjing, China: The mediating role of leisure activities and attitudes toward aging","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-11-05 17:26:53","doi":"10.21203/rs.3.rs-5307508/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d8009962-dccc-4b49-bdf4-23726d5b4541","owner":[],"postedDate":"November 5th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-11-21T12:08:26+00:00","versionOfRecord":[],"versionCreatedAt":"2024-11-05 17:26:53","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5307508","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5307508","identity":"rs-5307508","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}