How common anxiety and depression are among older adults with long-term illnesses in Zunyi, China, and what they relate to

The inclusion criteria were as follows: ① age ≥ 60 years; ② able to communicate normally; ③ able to sign informed consent and participate in the study voluntarily.

Exclusion criteria were as follows: ① People with severe schizophrenia, mania and other mental illnesses; ② Patients with severe hearing, vision and speech disorders.

From March 2022 to October 2023, a stratified random sampling method was adopted. Based on the requirements of the National Key R&D Program for Active Health and Aging Response, and considering multiple factors such as research objectives, actual distribution, data comparability, and resource limitations, medical institutions, elderly care institutions, and home-dwelling elderly people in Zunyi City, Guizhou Province were selected as survey subjects at a ratio of 5:1:3.

In the first stage, the representative areas were divided into three categories: medical institutions, elderly care institutions, and home-dwelling elderly people. Medical institutions included hospitals at all levels in Zunyi City, encompassing district people's hospitals, county people's hospitals, traditional Chinese medicine hospitals, township health centers, and community hospitals. Elderly care facilities included institutions at various levels in Zunyi City and its counties. Home-dwelling elderly individuals included those from various communities and villages across townships.

In the second stage, 10 departments were randomly selected from medical institutions, and all eligible subjects within the survey period were recruited. Ten elderly care institutions were chosen from each level of such institutions, and all eligible elderly people within the survey period were included. Ten residential communities or villages were selected from each community. Considering the possibility of ineligible data or refusal to participate in the survey, 2–3 additional locations in each area were selected as alternate households. All eligible subjects within the survey period were recruited. Ultimately, 5,593 subjects were recruited from medical institutions, 1,153 from elderly care institutions, and 3,175 home-dwelling elderly subjects were recruited.

By referring to the literature, the median prevalence of anxiety and depression was taken as ~35.00% (Lu et al.,). Based on the 95% confidence interval (CI), where α = 1–0.95 = 0.05,05 = 1.96,= 0.35, and δ = 0.01, the following formula was used to calculate the required minimum sample size, which was 8,740. To ensure a sufficient sample size, the sample size was increased by 10%, and the final sample size was 9,614 individuals. ²⁰²³ z P 2

SPSS29.0 statistical software was used, and the count data, when satisfying normal distribution, were expressed as mean ± standard deviation (x ± s), and the independent samples-test was used for comparison between the two groups, while thetest was used for comparison between the two groups when they were not normally distributed. Measurement data were expressed as, and comparisons between groups were made using the chi-square test or's exact probability method. one-wayregression was used to analyze potential correlates, and single factors found to be correlated were included in the multifactorialregression analysis, and stepwise entry of variables was used to determine the final influences on dementia.< 0.05 was taken as the difference being statistically significant. t Mannu-Whitney U n (%) Fisher logistic logistic P

A total of 9,998 subjects were included in this study, and 9,821 valid questionnaires were obtained. The effective recovery rate was 98.23%. A total of 177 questionnaires were invalid due to incomplete information, random responses, logical errors, etc. Of the 9,821 respondents included in the study, the mean age of the subjects was 71.89 ± 7.246 years, ranging from 60 to 98 years old, and the percentages of female and male participants were 51.70% and 48.30%, respectively. Nearly half of the population had less than elementary school education. Most of the respondents were married with multiple children and reported a personal monthly income of <RMB 2,000, 35.26% did not exercise, and 42.13% had little to no socialization.

The prevalence of anxiety was 26.83% (95% CI: 25.14–28.52), the prevalence of depression was 10.33% (95% CI: 8.46–12.20), and the prevalence of comorbid anxiety and depression was 6.88% (95% CI: 4.97–8.79). The age group of 71–79 had the highest prevalence. The prevalence was higher in females than in males, and higher in rural areas than in urban areas, as shown in. Among all participants, the highest proportion of subjects suffered from cardiovascular diseases (67.13%), followed by endocrine system diseases (29.16%), cerebrovascular diseases (15.76%), degenerative diseases (15.13%), respiratory system diseases (15.03%), digestive system diseases (3.43%), kidney diseases (2.44%), and cancer (1.17%), as shown in. Compared to patients with other chronic diseases, those with cardiovascular diseases exhibited higher prevalence rates of anxiety, depression, and the co-occurrence of anxiety and depression, as detailed in. Table 1 Figure 1 Table 2

Univariate analyses revealed that age, literacy, children's status, type of residence, mode of residence, average monthly household income, type of chronic disease, smoking, participation in social activities, physical activity, social support, ability to perform activities of daily living, self-assessed health status, nutritional status, frailty, and quality of sleep were the factors influencing the anxiety of older adults with chronic disease; age, literacy, children's status, type of residence, mode of residence, average monthly household income, type of chronic disease, participation in social activities, physical activity, social support, self-assessed health status, nutritional status, frailty, and quality of sleep; age, literacy, children's status, type of residence, mode of residence, average monthly family income, type of chronic disease, participation in social activities, physical exercise, social support, ability to perform activities of daily living, self-assessed health status, nutritional status, debilitating conditions, and sleep quality were the influencing factors for depression among older adults with chronic disease; the difference was statistically significant (< 0.05). Details are shown in. P Table 3

The results of multifactorialregression analysis showed that advanced age, high level of education, high average monthly household income, regular physical exercise, sufficient material and emotional support, and mild dependence in daily life were protective factors for the development of depressive illness in chronically ill older adults (< 0.05). Living in rural areas, moderate ability to perform activities of daily living, heavy dependence, poor self-assessed health, presence of malnutrition, presence of debility and in the pre-debilitating stage, and presence of sleep disorders were independent risk factors for depression among chronically ill older adults (< 0.05), and the multifactorial analysis is shown in. High literacy, high average monthly income of the family, regular physical exercise, frequent participation in social activities, sufficient material and emotional support, living in an elderly care facility, and mild dependence in daily life were protective factors for anxiety in chronically ill older adults (< 0.05). Advanced age, childlessness, moderate ability to perform activities of daily living, heavy dependence, poor self-assessed health status, presence of malnutrition, presence of debility and pre-debilitation, and sleep disorders were independent risk factors for anxiety in older adults with chronic diseases (< 0.05), and the multifactorial analysis is shown in. logistic P P P P Table 4 Table 5

This study investigated the prevalence of depression and anxiety among elderly patients with chronic diseases and found that the prevalence rates of anxiety and depression among the elderly were 26.83% and 10.33%, respectively. This study showed that the prevalence of anxiety was higher than the global level (16.5%), while the prevalence of depression was lower than the global level (19.2%) (Jalali et al.,). Compared with the results of surveys on elderly populations in foreign countries, the prevalence rates of anxiety and depression in this study were both lower than those of the elderly in Myanmar (39.4% for anxiety and 35.6% for depression) (Cho et al.,). When compared with various regions in Europe and Africa, the prevalence of anxiety in this study was higher than that of the elderly in those regions (14.1%−20.8%), but the prevalence of depression was much lower than that of the elderly in those regions (32.2%−47.1%) (Mutepfa et al.,; Andreas et al.,). Compared with the results of domestic surveys on elderly populations, the prevalence of anxiety in this study was similar to that in a study on community-dwelling elderly in Hunan Province (32.74%) (Lu et al.,). The prevalence of depression in this study was similar to that in a study on community-dwelling elderly in Shenzhen, China (10.4%) (Peng et al.,), but lower than that of the elderly in Xi'an (27.0%) (Yunming et al.,). The differences in prevalence rates are due to factors such as the assessment tools used, the economic development levels of different regions, regional characteristics, demographic compositions, and social and cultural environments. ^{2024 2021 2021 2017 2023 2024 2012}

Firstly, in terms of the long-term management and treatment of chronic diseases, cardiovascular diseases, which are the most common among chronic diseases, can lead to a decline in patients' physical functions. Patients need to take long-term medications and visit doctors regularly. They often worry about the deterioration of their condition, sudden death, or a decline in their quality of life. This uncertainty and worry about the prognosis of the disease can bring huge psychological pressure to patients, making them prone to anxiety and depression (Lopes and Kamau-Mitchell,). At the same time, patients with cardiovascular diseases often have elevated cortisol levels, which may induce anxiety and depression by affecting the hypothalamic-pituitary-adrenal (HPA) axis (Leenen et al.,). A study based on 71,214 participants found that anxiety and depression accelerated the formation of cardiometabolic risk factors (such as hypertension and diabetes) and significantly increased the risk of cardiovascular diseases. Depression and anxiety increased the risk of major cardiovascular events such as heart attacks or strokes by ~35% (Civieri et al.,). Secondly, the accessibility of healthcare is also a key factor. Zunyi is a region with relatively underdeveloped economy and limited medical resources, facing problems such as uneven distribution of medical resources and insufficient professional medical services. For example, the medical resources in Zunyi City are mainly concentrated in urban areas, and elderly people in rural areas have difficulty in obtaining timely mental health services, which intensifies their concerns about their health conditions and thus increases the prevalence of anxiety. In contrast, the prevalence of depression is lower than the global average, which may be related to the family structure and support system in Chinese society. In China, families are usually the main source of emotional support and daily care for the elderly. This close family bond may alleviate the elderly's depressive emotions to a certain extent. In addition, support programs from communities and the government may also provide a certain amount of psychological and social support for the elderly, thereby reducing the risk of depression. ^{2024 2017 2024}

In this study, advanced age was identified as a protective factor against depression. Research has shown that the prevalence of depression decreases with age (Wade and Cairney,). Some studies indicate that older age is associated with better mental health, characterized by lower levels of stress, worry, and negative affect, as well as higher levels of positive affect (Fields et al.,). Typically, increasing age is linked to markers of improved mental health, including factors that can reduce depression levels (Blazer,). Some studies suggest that this may be because older adults tend to identify their health issues earlier but face challenges such as limited treatment options and access to information, leading to prolonged periods without medication or regular check-ups. This, in turn, may reduce their focus on disease progression and subsequently lower the risk of mental health problems (Long et al.,). However, in this study, age was found to be a risk factor for anxiety, possibly because aging impairs perception, cognitive abilities, verbal expression, comprehension, help-seeking behavior, and disrupts treatment collaboration and adherence (Zhi et al.,). ^{1997 2022 2003 2024 2024}

In this study, half of the older adults had less than elementary school, and a lower level of education (less than elementary school) is one of the risk factors for anxiety and depression. A study from France showed that people with a lower level of education have a higher risk of anxiety and depression (Joannès et al.,). One of the reasons for this is that the level of education can lead to a lack of health knowledge and health concepts among the elderly, which in turn affects the health care behaviors of elderly people in compliance. At the same time, people with low education level are more likely to suffer from the pressure of economic difficulties, which makes it difficult to get a good job, thus affecting their mental health. Furthermore, our study also showed that the lower the economic situation, the higher the prevalence of anxiety and depression. Since the included older adults all suffered from one or more chronic diseases that require long-term treatment and management, including medication, oxygen therapy, rehabilitation training, and other therapies, the cost of these treatments may impose a heavy financial burden on patients and families (Miao et al.,). What's more, because Zunyi City belongs to the hinterland of Southwest China and is relatively backward in terms of economic level, half of the elderly people it surveyed live in rural areas, and the elderly people mainly rely on the farming economy, with one crop a year, and the fact that the land isn't fertile, and their monthly incomes are low and unstable, which leads to extreme caution in the amount they spend on daily expenses. In contrast, the elderly in this study, all of whom have chronic diseases, require frequent medical treatment, and the accumulation of medical expenses may be beyond affordability, generating financial stress and anxiety, which may lead to symptoms of anxiety and depression. In addition, older adults with chronic diseases require long-term medication to maintain their health, and in this case, older adults have limited pensions or retirement funds, and the fear of depleting their savings or burdening family members with ongoing medical expenses may further lead to stress and depression. ^{2023 2022}

Studies have shown that rural areas typically exhibit a severe shortage of mental health services compared to urban settings (Miao et al.,; Colon-Rivera and Dixon,). As China's rapid urbanization has resulted in more young people leaving rural areas in search of employment opportunities, the proportion of older people living alone in rural areas has gradually increased. The gap between urban and rural areas in terms of income, social security system and infrastructure development has exacerbated the sense of loneliness among rural elderly living alone (Ren and Lu,). As they are living alone, communication with the outside world is further reduced and they feel more isolated due to the loss of their social roles, and they feel more depressed or lonely compared to their relatives living with them and elderly people living in institutions (Hu et al.,), which can lead to the development of anxiety (Yu et al.,). In addition, studies have shown that living in an institution is a protective factor because there are more people of the same age in the institution who can interact with each other, the institution can provide a diversified model, there are professional caregivers who can provide around-the-clock detailed services and the nursing home can provide relatively convenient access to medical care and rehabilitation conditions (Li,). This study also demonstrated that chronically ill older adults in rural areas have more fragile social support compared to urban populations, a finding supported by an Ecuadorian study (Madrid Miles et al.,). Since social support is one of the key factors in alleviating anxiety and depression symptoms and improving mental health, the lack of social support can cause a more pronounced mortality rate due to anxiety and depression symptoms (Rowland et al.,). Therefore, there is a need to enhance healthcare and social support for patients with anxiety and depression. ^{2022 2020 2021 2023 2020 2024 2022 2023}

This study indicates that nearly half of the participants rarely or never engage in physical exercise or social activities, which is one of the risk factors for anxiety and depression among the elderly. A study has shown that participating in exercise, whether individually or in groups, can alleviate anxiety, and higher frequency of physical activity is associated with reduced levels of depression and anxiety (McMahon et al.,). Additionally, research suggests that regular participation in social activities helps avoid negative emotions and improves neurological function (Wang R. et al.,). Furthermore, a study highlights that chronic diseases in the elderly can lead to physical impairment and functional limitations, which may negatively impact their ability to perform daily living activities, potentially explaining why older adults are less likely to engage in physical exercise and social activities. However, in this study, mild dependency in daily living activities was identified as a protective factor. This is because mild dependency is more likely to draw attention and support from family members and others, and individuals with mild dependency can manage their lives without relying heavily on external assistance, making them less prone to experiencing symptoms of anxiety and depression. ^{2017 2019}

The results of this study show that poor self-assessed health status is one of their risk factors. Self-assessed health status depends not only on the actual health status of patients with chronic diseases, but also on their perceived health status, which to a certain extent reflects older people's awareness of their own physiological and psychological conditions and changes, and those who self-assessed as fair or unhealthy tended to be lower than those who self-assessed as healthy in terms of their psychological status and social adjustment, and they were at increased risk of developing depression and anxiety (Fang et al.,). In addition, it has been shown that disturbed sleep quality increases the risk of reporting poor health, and self-reported rest/sleep deprivation appears to be a strong predictor of self-assessed health (Frange et al.,; Nordin et al.,). In our current multitude of studies, sleep disorders are one of the influencing factors that contribute to the occurrence of depression and anxiety in the elderly population. As anxiety and depression are usually accompanied by concerns and worries about falling asleep, it leads to the formation of a negative cycle of insomnia and anxiety-depression perpetuation (Fang et al.,). Meanwhile, some studies have shown a causal relationship between sleep disorders and debility (Lu et al.,). Debilitation leads to a significant increase in hospitalization rates, hospitalization costs, and morbidity and mortality rates, which seriously affects their quality of life, increases healthcare consumption, and aggravates the burden on families and society (Gong et al.,). Increased levels of debility are accompanied by increased levels of anxiety and depression (Hiriscau and Bodolea,). In addition, with studies have shown that malnutrition can cause debilitation (Zhao et al.,). The bidirectional correlation between nutritional status, which is an important modifiable factor of frailty, which leads to malnutrition, and malnutrition, which leads to multi-systemic dysfunction and further aggravates frailty, creates a vicious circle in the elderly population. Therefore, regular attention to the physical health status of older persons is essential. ^{2024 2014 2024 2019 2024 2022 2019 2021}

First, only self-assessment tools were used to determine the presence of anxiety and depression, and no confirmation was made through diagnoses by psychiatrists. It is recommended that further research be conducted to gain a deeper understanding of the mental health of elderly patients with chronic diseases in Zunyi. Second, due to cultural, healthcare, and socioeconomic differences, the results may not be generalizable to other regions. Third, the cross-sectional design can only provide static data at a specific moment and cannot observe the changes in the prevalence of anxiety and depression and their influencing factors over time. Fourth, the cross-sectional design usually relies on self-reported data from respondents, which may be subject to recall bias or information bias. Future research should conduct longitudinal follow-up studies in multiple regions or institutions, analyze regional differences, and further explore the interaction mechanisms between chronic diseases, anxiety, and depression to provide scientific evidence for policy-making and data support for policy improvement.