رابطه فعالیت‌های روزمره زندگی با پریشانی روان‌شناختی در سالمندان: نقش میانجی احساس تنهایی

Today, paying attention to older adults and trying to improve their psychological health seems highly important. Therefore, identifying the potential factors that can affect the reduction or increase their psychological distress appear to be crucial and significant for early diagnosis and prevention of psychological distress. Consequently, this study aimed to investigate the mediating role of loneliness in the relationship between activities of daily living (ADLs) and psychological distress in older adults. This was a correlational study, of path analysis type. The statistical population included all older adults living in Ilam, Iran in 2022, among whom 385 were selected using convenience sampling method. The participants of this study filled out Lovibond’s depression, anxiety and stress scale, Mahoney and Barthel’s ADLs questionnaire and the Russell et al.’s loneliness questionnaire. The collected data were analyzed using Pearson’s correlation coefficient and path analysis in SPSS-25 and Amos-25 software, respectively. The results of path analysis demonstrated that there is a negative direct relationship between ADLs and loneliness, a negative direct relationship between ADLs and psychological distress, and a positive direct relationship between loneliness and psychological distress. ADLs also had an indirect and significant relationship with psychological distress through the mediating role of loneliness (p<.05, β=-.17). According to the results of the current research, it can be said that targeting the ADLs and loneliness in relation to treatments and psychological services can be effective for older adults. Therefore, it is suggested that counselors and psychologists working in the field of older adults take a constructive step in reducing the psychological distress of older adults by using measures to help reduce their feeling of loneliness.
EXTENDED ABSTRACT
Introduction
The examination of psychosocial variables in older adults, as a vulnerable and ever-increasing population, is of paramount importance. Statistics indicate that nearly half of older adults experience psychological distress, emphasizing the significance of identifying factors that can either mitigate or exacerbate such distress for early detection and prevention. Research suggests that older individuals at risk of losing independence in their daily activities and self-care should be prioritized for preventive interventions. Although studies have indicated the relationship between activities of daily living (ADLs) and psychological distress in older adults, there is scarce research on the underlying mechanisms and the condition of the relationship between these variables among older adults in Iran. Additionally, loneliness has been found to be associated with both ADLs and psychological distress, with one of the consequences of impairment in ADLs being the feeling of loneliness, which is also linked to an increase in psychological distress. given the profound impact of these variables on the well-being of older adults and the existing gap in the research literature, the present study aimed to investigate the mediating role of loneliness in the relationship between ADLs and psychological distress among older adults.
Method
It was a descriptive-correlational study of path analysis type. The statistical population consisted of all individuals aged 60   and   over   living in Ilam, Iran during the year 2022, among whom a sample of 400 participants was selected using convenience sampling method. The inclusion criteria were as follows: (1) having at least a primary school education, (2) being aged 60 or older, (3) not residing in older adults’ care homes, and (4) being residents of Ilam. Exclusion criteria included severe physical or mental health problems that hindered participation in the study. Data collection tools included the Lovibond’s Depression, Anxiety, and Stress Scale, the Mahoney and Barthel’s ADLs Questionnaire, and the Russell’s Loneliness Scale. Having obtained the necessary permits, we collected data in various public locations in different parts of the city, such as parks, mosques, and pilgrimage sites, where the likelihood of older adults being present was high, adhering to health protocols. Then the initial interviews were conducted with individuals meeting the specified criteria, and they were invited to participate in the study. Once informed consent was obtained, participants were provided with the questionnaires, along with necessary instructions for completion. They were asked to carefully read the items and select the most appropriate responses. Following the questionnaire review and response validity checks, 15 questionnaires were removed from the final analysis. Ultimately, data obtained from 385 questionnaires comprised the final sample for analysis. The collected data were subjected to statistical analysis using Pearson’s correlation coefficients and path analysis through SPSS-25 and Amos-25.
Results
Prior to conducting the data analysis, it was determined that the distribution of scores for all research variables followed a normal distribution. The results also indicated a lack of correlation between errors and non-linearity among the variables. To test the research hypotheses, the initial step involved examining the correlations between the research variables. Based on the Pearson’s correlation analysis, the results indicated a significant negative correlation between ADLs and psychological distress, a significant negative correlation between the ADLs and loneliness, and a significant positive correlation between loneliness and psychological distress. Given the significant correlations between the research variables, the next phase of the analysis involved evaluating the hypothesized model and assessing its fit, which was accomplished through the application of path analysis. The final model can be seen in the Figure 1.
The fitness indices for the obtained model were as follows: X² = 5.76, df = 2, X²/df = 2.38, GFI =.99, IFI =.98, NFI =.96, CFI =.97, AGFI =.97, NNFI =.95, RMSEA =.065. These indices indicate that the hypothesized model in the current research exhibits a good fit. To assess and determine the significance of indirect paths in the research model, bootstrapping was employed using Amos software, the results of which illustrated that the lower and upper bounds and the confidence interval for the mediating role of loneliness between ADLs and psychological distress were .254, .387, and .01 (P<.01), respectively. Therefore, considering the confidence level (P<.01), loneliness serves a significant mediating role in the relationship between ADLs and psychological distress.
Conclusion
The current research provides empirical evidence for pathways that link ADLs to psychological distress in a sample of older adults living in Ilam. Limitations or disabilities in performing ADLs are directly and indirectly associated with psychological distress. Constraints in ADLs negatively impact mental health in various ways. Older individuals with limitations in ADLs often experience significant loneliness, which, in turn, can be a significant risk factor for impaired emotional functioning.
When the mobility of older individuals is restricted, they are likely to have less interaction with their families and friends, and their social participation and interactions are limited, making it challenging for them to establish and maintain meaningful social relationships, leading to feelings of loneliness. Consequently, psychological problems such as depression, stress, and anxiety can easily manifest in them. These findings represent a crucial step in understanding the underlying mechanisms of the relationship between ADLs and psychological distress. Therefore, special attention should be given to older individuals who simultaneously experience limitations in ADLs and feelings of loneliness. By making efforts to reduce the level of loneliness through strengthening family and social support in older adults, we can contribute to improving their psychological well-being.
Ethical Consideration
Ethical Code
The present article was conducted independently with the necessary authorization from the Research Deputy of the Islamic Azad University, Ilam Branch.
Financial Support
 This study had no financial support.
Authors’ Contributions
 S.M: Conceptualization, Writing-Original Draft, writing-Review & Editing; W.A: Methodology, Formal analysis, and Resources; H.V: Data Curation
Conflict of Interest
 The authors had no conflicts of interest.
Acknowledgments
We would like to express our gratitude to the esteemed older participants of the study and the personnel at the Islamic Azad University, Ilam Branch, who facilitated the execution of this research.
References
Ali, S. H., Islam, T., Pillai, S., Kalasapudi, L., Mammen, S., Inala, S., Kalasapudi, V., Islam, N. S., & Gunness, H. (2021). Loneliness and mental health outcomes among South Asian older adult immigrants in the United States: A Cross-sectional study. International Journal of Geriatric Psychiatry, 36 (9), 1423-1435. https://doi.org/10.1002/gps.5549
Akhavan-Abiri, F., Shairi, M., & Gholami-Fesharaki, M. (2018). Structural relationships between attachment style and psychological distress: Mediating role of cognitive emotion regulation. Journal of Clinical Psychology, 10 (3), 63-76. https://doi.org/10.22075/JCP.2019.15976.1528 [Persian]
Alizadeh, M., Rahimi, A., Arshinji, M., Sharifi, F., Arzaghi, M., & Fakhrzadeh. H. (2014). Physical health status and socio-economic outcomes on elderly in Tehran metropolitan area. Iranian Journal of Diabetes and Metabolism, 13 (1), 29-37. http://ijdld.tums.ac.ir/article-1-5089-en.html [Persian]
Allahyari, E., Keramati, M., & Kamali, M. (2020). Predicting Elderly Depression Prevalence in Different Iranian Ethnicities and Associated Factors. Salmand: Iranian Journal of Ageing, 15 (1), 94-103. http://salmandj.uswr.ac.ir/article-1-1915-en.html [Persian]
Antony, M. M., Bieling, P. J., Cox, B. J., Enns, M. W., & Swinson, R. P. (1998). Psychometric properties of the 42-item and 21-item versions of the Depression Anxiety Stress Scales in clinical groups and a community sample. Psychological assessment, 10 (2), 176-181. https://doi.org/10.1037/1040-3590.10.2.176
Arslantas, D., Ünsal, A., & Ozbabalık, D. (2014). Prevalence of depression and associated risk factors among the Elderly in Middle Anatolia, Turkey. Geriatrics and Gerontology International, 14 (1), 100–108. https://doi.org/10.1111/ggi.12065
Asghari Moghaddam, M., Saed, F., Dibajnia, P., & Zangeneh, J. (2008). A Preliminary validation of the Depression, anxiety and stress scales (DASS) in non-clinical sample. Clinical Psychology and Personality, 6 (2), 23-38. https://cpap.shahed.ac.ir/article_2610.html [Persian]
Ataeifar, R., Amiri, S., & Nadi, M. A. (2016). Investigating the Relationship between effective communication of spouse and father—child relationship (test pattern causes to education parents). International Education Studies, 9 (7), 98. https://doi.org/ 10.5539/ies.v9n7p98
Atkins, J., Naismith, S. L., Luscombe, G. M., & Hickie, I. B. (2013). Psychological distress and quality of life in older persons: Relative contributions of fixed and modifiable risk factors. BMC Psychiatry, 13 (1), 249. https://doi.org/10.1186/1471-244X-13-249
Burholt, V., Windle, G., & Morgan, D. J. (2017). A Social model of loneliness: The roles of disability, social resources, and cognitive impairment. Gerontologist, 57 (6), 1020–1030. https://doi.org/10.1093/geront/gnw125
Chiang, K. J., Chu, H., Chang, H. J., Chung, M. H., Chen, C. H., Chiou, H. Y., et al. (2010). The Effects of reminiscence therapy on psychological well-being, depression, and loneliness among the institutionalized aged. International Journal of Geriatric Psychiatry, 25 (4), 380-388. https://doi.org/ 10.1002/ gps.2350
Daniel, K. (2013). Loneliness and depression among university Students in Kenya. Global Journal of Human Social Science Research, 13 (4), 11-18.https://socialscienceresearch.org/index.php/GJHSS/article/view/795
Dehghanpouri, H., Ebrahimi, S., & Chavoshi, S. (2021). Investigate the Effect of death anxiety on the psychological distress of ecotourist elderly by the Mediation role of mindfulness. Quarterly Journal of Social Work, 10 (3), 15-26. http://socialworkmag.ir/article-1-693-en.html [Persian]
Dohrenwend, B. P. (2006). Inventorying stressful life events as risk factors for psychopathology: Toward resolution of the problem of intracategory variability. Psychological Bulletin, 132 (3), 477_495. https://doi.org/10.1037/0033-2909.132.3.477.
Feng, D., Ji, L., & Xu, L. (2014). Mediating effect of social support on the Association between functional disability and psychological distress in older adults in rural China: Does age make a difference? PLoS One, 9 (6), e100945. https://doi.org/ 10.1371/journal.pone.0100945
Gao, J., Gao, Q., Huo, L., & Yang, J. (2022). Impaired activity of daily living status of the older adults and its influencing factors: A Cross-sectional study. International Journal of Environmental Research and Public Health. 19 (23), 15607. https://doi.org/ 10.3390/ ijerph192315607
Gulpers, B., Ramakers, I., Hamel, R., K¨ohler, S., Oude Voshaar, R., & Verhey, F. (2016). Anxiety as a Predictor for cognitive decline and dementia: A Systematic review and meta-analysis. The American Journal of Geriatric Psychiatry, 24 (10), 823–842. https://doi.org/10.1016/j.jagp.2016.05.015
Gyasi, R. M., & Phillips, D. R. (2020). Risk of psychological distress among community-dwelling older adults experiencing spousal loss in Ghana. Gerontologist, 60 (3), 416–427. https://doi.org/10.1093/geront/gnz052
Hacihasanoğlu, R., Yildirim, A., & Karakurt, P. (2012). Loneliness in elderly individuals, level of dependence in activities of daily living (ADL) and influential factors. Archives of Gerontology and Geriatrics, 54 (1), 61-66. https:// doi.org/10.1016/j.archger.2011.03.011
He, M., Ma, J., Ren, Z., Zhou, G., Gong, P., Liu, M., Yang, X., Xiong, W., Wang, Q., Liu, H., & Zhang, X. (2019). Association between activities of daily living disability and depression symptoms of middle-aged and older Chinese adults and their spouses: A Community based study. Journal of Affective Disorders, 242 (1), 135–142. https://doi.org/ 10.1016/ j.jad.2018.08.060
Heinrich, L. M., & Gullone, E. (2006). The clinical significance of loneliness: A Literature review. Clinical psychology review, 26 (6), 695-718. https://doi.org/10.1016/j.cpr.2006.04.002
Henry, J. D., & Crawford, J. R. (2005). The short‐form version of the Depression Anxiety Stress Scales (DASS‐21): Construct validity and normative data in a large non‐clinical sample. British journal of clinical psychology, 44 (2), 227-39. https://doi.org/10 1348/ 014466505X29657
Holvast, F., van Hattem, B. A., Sinnige, J., Schellevis, F., Taxis, K., Burger, H., & Verhaak, P. F. M. (2017). Late-life depression and the Association with multimorbidity and polypharmacy: A Cross-sectional study. Family Practice, 34 (5), 539–545. https:// doi.org/ 10.1093/fampra/cmx018
Jing, Z., Li, J., Fu, P. P., Wang, Y., Yuan, Y., Zhao, D., Hao, W., Yu, C., & Zhou, C. (2021). Physical multimorbidity and lifetime suicidal ideation and plans among rural older adults: The Mediating role of psychological distress. BMC Psychiatry, 21 (1), 78. https://doi.org/10.1186/s12888-021-03087-4
Kaasa, K. (2009). Loneliness in old age: Psychosocial and health predictors. Norsk Epidemiologi, 8 (2). 195-201. https://doi.org/10.5324/nje.v8i2.468
Khajavi, D., & Parsa, Z. (2014). The Development of psychometric properties of "the Elderly's activities of daily life scale". Journal of Sports and Motor Development and Learning, 6 (1), 91-108. https://doi.org/10.22059/jmlm.2014.50192 [Persian]
Khazem, L. R., & Anestis, M. D. (2019). Do physical disabilities differentiate between suicidal ideation and attempts? An Examination within the lens of the ideation to action framework of suicide. Journal of Clinical Psychology, 75 (4), 681–695. https://doi.org/ 10.1002/jclp.22735
Koç, Z. (2015). The investigation of factors that influence self-care agency and daily life activities among the Elderly in the Northern region of Turkey. Collegian, 22 (3), 251–258. https://doi.org/ 10. 1016/j.colegn.2014.01.002
Kong, D., Solomon, P., & Dong, X., (2019). Depressive symptoms and onset of functional disability over 2 years: A Prospective cohort study. Journal of American Geriatrics Society, 67 (3), 538–544. https://doi.org/ 10.1111/jgs. 15801
Konno, Y., Nagata, M., Hino, A., Tateishi, S., Tsuji, M., Ogami, A., Yoshimura, R., Matsuda, S., & Fujino, Y. (2021). Association between loneliness and psychological distress: A Cross-sectional study among Japanese workers during the COVID-19 pandemic. Preventive Medicine Reports, 24 (10229), 101621. https://doi.org/10.1016/j.pmedr.2021.101621
Landi, F., Abbatecola, A. M., Provinciali, M., Corsonello, A., Bustacchini, S., Manigrasso, L., & Lattanzio, F. (2010). Moving against frailty: Does physical activity matter? Biogerontology, 11 (5), 537-545. https://doi.org/10.1007/s10522-010-9296-1
Lin, I. F., & Wu, H. S. (2011). Does informal care attenuate the Cycle of ADL/IADL disability and depressive symptoms in late life? The Journal of Gerontology. Series B, Psychological Sciences and Social Sciences, 66 (5), 585–594. https://doi.org/10.1093/geronb/gbr060
Litwin, H., Levinsky, M., & Schwartz, E. (2020). Network type, transition patterns and well-being among older Europeans. European Journal of Ageing, 17 (2), 241–250. https://doi.org/10.1007/s10433-019-00545-7
Mahoney, F. I., & Barthel, D. W. (1965). Functional evaluation: Barthel Index. Maryland State Medical Journal, 14 (2), 61 – 65.
Menec, V. H., Newall, N. E., Mackenzie, C. S., Shooshtari, S., & Nowicki, S. (2020). Examining social isolation and loneliness in combination in relation to social support and psychological distress using Canadian Longitudinal Study of Aging (CLSA) data. PLoS One, 15 (3), e0230673. https://doi.org/ 10. 1371/journal.pone.0230673
Miri, Kh., Bahrami, M., Vafainnya, R., & Gholamzadeh, T. (2017). Relationship between feeling of loneliness and activities of daily living among the Elderly. Journal of Research & Health, 7 (3), 834- 840. https://doi.org/ 10. 18869/acadpub.jrh.7.3.834
Molajafar, H., Pour-Sharifii, H., Meschi, F., Bermas, H., & Tajeri, B. (2017). Effectiveness of protocol based on integrated view on psychological distress in elderly. Journal of Arak University Medical Sciences, 20 (3), 88-97. http://jams.arakmu.ac.ir/article-1-5061-en.html [Persian]
Momeni, K., Amani, R., Janjani, P., Majzoobi, M. R., Forstmeier, S., & Nosrati, P. (2022). Attachment styles and happiness in the Elderly: The Mediating role of reminiscence styles. BMC Geriatrics, 22 (1), Article 349. https://doi.org/10.1186/s12877-022-03053-z
Momeni, K., Amani, R., Janjani, P., Majzoobi, M., & Hadian Hamedani, K. (2021). The Relationship between attachment styles with positive and negative affect in the Elderly: The Mediating role of reminiscence styles. Aging Psychology, 7 (4), 422-407. https://doi.org/10.22126/JAP.2022.7492.1606 [Persian]
Moradi, A., & Shariatmadari, A. (2016). The Comparison between death anxiety and loneliness among the Elderly with optimistic and pessimistic life orientation. Aging Psychology, 2 (2), 133-141. [Persian]
Nazari, H., Rashedi, V., Mohammadi, H., & Yousefi, M. (2015). Relationship between cognitive status and activities of daily living among the Elderly of nursing homes. Journal of Kermanshah University of Medical Sciences, 18 (12), 744-6. https://doi.org/10.22110/jkums.v18i12.2390
Nie, Y., Hu, Z., Zhu, T., & Xu, H. (2020). A cross-sectional study of the prevalence of and risk factors for suicidal ideation among the Elderly in nursing homes in Hunan Province, China. Frontiers in Psychiatry, 11, 339. https://doi.org/ 10.3389/fpsyt.2020.00339
Ohayashi, H., & Yamada, S. (2012). Psychological distress: Symptoms, causes, and coping. Nova Science Publishers
Paul, C., Ayis, S., & Ebrahim, S. (2006). Psychological distress, loneliness and disability in old age. Psychology, Health and Medicine, 11 (2), 221–232. https://doi.org/10.1080/13548500500262945
Pearlin, L. I. (1987). The family as a context of the stress process. Stress and health: Issues in research methodology, 143-165.
Preville, M., Hebert, R., Bravo, G., & Boyer, R. (2002). Predisposing and facilitating factors of severe psychological distress among frail elderly adults. Canadian Journal on Aging – Revue Canadian Journal on Ageing, 21 (2), 195–204. https://doi.org/10.1017/S071498080000146X
Rashedi, V., Gharib, M., & Yazdani, A. A. (2014). Social participation and mental health among older adults in Iran. Iranian Rehabilitation Journal, 12 (1), 9-13. http://irj.uswr.ac.ir/article-1-402-en.html
Ridner, S. H. (2004). Psychological distress: Concept analysis. Journal of advanced nursing, 45 (5), 536-545. https://doi.org/10.1046/j.1365-2648.2003.02938.x
Russell, D. W. (1996). UCLA Loneliness Scale (Version 3): Reliability, validity, and factor structure. Journal of Personality Assessment, 66 (1), 20-40. https://doi.org/10.1207/s15327752jpa6601_2
Russell, D., Paplau, L. A., & Ferguson, M. L. (1978). Developing a measure of loneliness. Journal of Personality Assessment, 42 (3), 290 – 294. https://doi.org/10.1207/s15327752jpa4203_11
Sahebi, A., Asghari, M. J., & Salari, R. S. (2005). Validation of depression anxiety and stress scale (DASS-21) for an Iranian population. Journal of Developmental Psychology Iranian Psychologist, 1 (4), 36-54. https://jip.stb.iau.ir/article_512443_en.html [Persian]
Salmani, M., & Zoghi, L. (2022). The Relationship between loneliness, spiritual intelligence and general health with death anxiety in the Elderly: The Mediating role of mindfulness. Aging Psychology, 8 (1), 69-55. https://doi.org/10.22126/jap.2022.7586.1609 [Persian]
Sau, K., Amin, K.P., Sharma, A., & Fakorede, S. O. (2015). Participation in activities of daily living can reduce loneliness in older adults. Indian Journal of Psychiatry, 57 (4), 430–431. https://doi.org/ 10.4103/0019-5545.171857
Schutter, N., Holwerda, T., Stek, M., Dekker, J., Rhebergen, D., & Comijs, H. (2017). Loneliness in older adults is associated with diminished cortisol output. Journal of Psychosomatic Research, 95, 19-25. https://doi.org/10.1016/j.jpsychores.2017.02.002
Shahyad, S., Besharat, M. A., Asadi, M., Alipour, A. S., & Miri, M. (2011). The Relation of attachment and perceived social support with life satisfaction: Structural equation model. Procedia-Social and Behavioral Sciences, 15, 952-6. https://doi.org/10.1016/j.sbspro.2011.03.219
Sherwood, S., Morris, J., Mor, V., & Gutkin, C. (1977). Compendium of measures for describing and assessing long-term care populations. Boston: Hebrew rehabilitation center for the Aged.
Schneider, S., Diehl, K., G¨orig, T., Schilling, L., De Bock, F., Hoffmann, K., Albrecht, M., Sonntag, D., Fischer, J. (2017). Contextual influences on physical activity and eating habits -options for action on the community level. BMC Public Health, 17, 760.
Sodani, M., Shogaeyan, M., & Neysi, A. (2012). The effect of group logo - therapy on loneliness in retired men. Research in Cognitive and Behavioral Sciences, 2 (1), 43-54. https://cbs.ui.ac.ir/article_17287.html?lang=en [Persian]
Stafford, A. M., & Draucker, C. B. (2019). Emerging adult women’s views-of-self in intimate partner relationships that are troubled. Issues in Mental Health Nursing, 40 (4), 289–296. https://doi.org/10.1080/01612840.2018.1524529
Suedfield, P. (1987). Past the Reflection and through the Looking glass: Extending loneliness research. Journal of Social Behavior and Personality, 2 (2), 51.
Taheri Tanjani, P., & Azadbakht, M. (2016). Psychometric properties of the Persian version of the Activities of daily living scale and instrumental activities of daily living scale in elderly. Journal of Mazandaran University Medical Sciences, 25 (132), 103-112. http://jmums.mazums.ac.ir/article-1-6766-en.html [Persian]
Tasca, G. A., Kowal, J., Balfour, L., Ritchie, K., Virley, B., & Bissada, H. (2006). An Attachment insecurity model of negative affect among women seeking treatment for an eating disorder. Eating Behaviors, 7 (3), 252-257. https://doi.org/10.1016/j.eatbeh.2005.09.004
Tian, Q. (2016). Intergeneration social support affects the subjective well-being of the elderly: Mediator roles of self-esteem and loneliness. Journal of Health Psychology, 21 (6),1137-44. https://doi.org/10.1177/1359105314547245
Turan, N., & Erdur-Baker, Ö. (2010). The Contribution of rumination and internal working models of attachment to psychological symptoms. Procedia- Social and Behavioral Sciences, 5, 1185-1189. https://doi.org/ 10.1016/ j.sbspro.2010.07.258
Wade, D., & Hewer, R. (1987). Functional abilities after stroke: Measurement, natural history and prognosis. Journal of Neurological Neurosurgery and Psychiatry, 50 (2), 177-182. https://doi.org/10.1136/jnnp.50.2.177
Wei, J., Ying, M., Xie, L., Chandrasekar, E. K., Lu, H., Wang, T., & Li, C. (2019). Late-life depression and cognitive function among older adults in the U.S.: The National health and nutrition examination survey, 2011-2014. Journal of Psychiatric Research, 111, 30–35. https://doi.org/10.1016/j.jpsychires.2019.01.012
Wormald, A. D., McCallion, P., & McCarron, M. (2019). The Antecedents of loneliness in older people with an intellectual disability. Research in Developmental Disabilities, 85, 116–130. https://doi.org/10.1016/j.ridd.2018.11.009
Xiao, S., Shi, L., Xue, Y., Zheng, X., Zhang, J., Chang, J., Lin, H., Zhang, R., & Zhang, C. (2022). The Relationship between activities of daily living and psychological distress among Chinese older adults: A Serial multiple mediation model. Journal of Affective Disorders. 300, 462-468. https://doi.org/10.1016/j.jad.2021.12.069
Xiao, S., Shi, L., Dong, F., Zheng, X., Xue, Y., Zhang, J., Xue, B., Lin, H., Ouyang, P., & Zhang, C. (2022). The Impact of chronic diseases on psychological distress among the older adults: The Mediating and moderating role of activities of daily living and perceived social support. Aging Ment Health, 26 (9), 1798-1804. https://doi.org/10.1080/13607863.2021.1947965
Xie, H., Peng, W., Yang, Y., Zhang, D., Sun, Y., Wu, M., Zhang, J., Jia, J., & Su, Y. (2018). Social support as a Mediator of physical disability and depressive symptoms in Chinese elderly. Archives of Psychiatric Nursing, 32 (2), 256–262. https://doi.org/10.1016/j.apnu.2017.11.012
Xu, H., Qin, L., Wang, J., Zhou, L., Luo, D., Hu, M., Li, Z., & Xiao, S. (2016). A Cross-sectional study on risk factors and their interactions with suicidal ideation among the Elderly in rural communities of Hunan, China. BMJ Open, 6 (4), e010914. https://doi.org/10.1136/bmjopen-2015-010914
Xue, Y., Lu, J., Zheng, X., Zhang, J., Lin, H., Qin, Z., & Zhang, C. (2021). The relationship between socioeconomic status and depression among the older adults: The Mediating role of health promoting lifestyle. Journal of Affective Disorders, 285, 22–28. https://doi.org/10.1016/j.jad.2021.01.085
Yang, L., Zhao, M., Magnussen, C. G., Veeranki, S. P., & Xi, B. (2020). Psychological distress and mortality among US adults: Prospective cohort study of 330 367 individuals. The Journal of Epidemiology and Community Health, 74 (4), 384–390. https://doi.org/10.1136/jech-2019-213144
Yanguas, J., Pinazo-Henandis, S., & Tarazona-Santabalbina, F. J. (2018). The Complexity of loneliness. Acta Biomedica Atenei paramensis, 89 (2), 302–314. https://doi.org/10.23750/abm.v89i2.7404