key: cord-0877793-791lqi2i authors: Wang, Yi; Fu, Peipei; Li, Jie; Jing, Zhengyue; Wang, Qiong; Zhao, Dan; Zhou, Chengchao title: Changes in psychological distress before and during the COVID-19 pandemic among older adults: the contribution of frailty transitions and multimorbidity date: 2021-03-11 journal: Age Ageing DOI: 10.1093/ageing/afab061 sha: c1991956203542b701829840866790ac9612d0a3 doc_id: 877793 cord_uid: 791lqi2i AIM: To investigate changes in psychological distress in community-dwelling older adults before and during the COID-19 pandemic, and the contribution of frailty transitions and multimorbidity in predicting the psychological distress. METHODS: Prospective repeated-measures cohort study on a sample of participants aged 60 and over. A total of 2, 785 respondents at the baseline (May 2019) were followed during the COVID-19 (August 2020). The changes in psychological distress before and during the COVID-19 were assessed using generalized estimation equations with adjusting for sex, age, education, economic status, marital status, tea drinking status, smoking status, alcohol drinking status, sedentary time, sleep quality and ADL. RESULTS: The psychological distress of older people has significantly increased in August 2020 compared with May 2019. Both older adults who remained frail and transitioned into frail state reported more psychological distress during the COVID-19. Similarly, both pre-existing multimorbidity and emerging multimorbidity groups were associated with more psychological distress. The group of frailty progression who reported new emerging multimorbidity showed more increase in psychological distress, in comparison with those remained non-frail state who reported no multimorbidity. CONCLUSION: Psychological distress has increased among the community-dwelling older adults during the COVID-19 pandemic, and sustained and progressive frail state, as well as multimorbidity were all associated with a greater increase of psychological distress. These findings suggest that future public health measures should take into account the increased psychological distress among older people during the COVID-19 pandemic, and the assessment of frailty and multimorbidity might help in warning of psychological distress. The outbreak of coronavirus disease 2019 (COVID-19) has rapidly spread worldwide and the World Health Organization (WHO) has declared the outbreak of COVID-19 a pandemic on 11 March 2020 [1] . Although China has controlled the pandemic quickly, there is still a risk of sporadic cases, imported cases and clusters of outbreaks for a long period [2] . Thus, the restrictions in China are remained, including some quarantine or isolation measures still in place, movement restrictions (needing health code), entry and exit registration, etc. Whether the COVID-19 outbreak is effectively controlled or not, the widespread contagion, restrictions on going outdoors, financial losses, and fewer opportunities of interpersonal contact may lead to a negative impact on mental health for general public [3, 4] . It is reported that the risk of contracting and dying from COVID-19 is increased in older people aged 60+ [5, 6] , thus, the pandemic may cause worse mental health among older people due to the fear of being infected with COVID-19. However, cross-sectional studies [7] [8] [9] are unable to assess the magnitude of its impact due to lack of pre-COVID-19 data. We found no longitudinal community-based studies to investigate the same older individuals' changes in psychological distress before and during the COVID-19 pandemic in China. During this pandemic, the clinical importance of frailty and its assessment has been gradually highlighted [10, 11] . Frailty, a critical aging-related clinical syndrome of reduced physiological reserve with diminished homeostasis [12] , is a vital risk factor for predicting severe COVID-19 disease [13] . Previous studies have shown the association between frailty and mental health [14, 15] , however, these have largely been based on comparisons between frail and non-frail individuals. What we want to emphasize is that frailty is a dynamic process with the potential for both frailty progression and recovery from a frail to a non-frail state over time [16, 17] . In other words, the effects of frailty on health are not static. Understanding how dynamic nature of frailty impact mental health among older people during the COVID-19 is critical to inform targeted measures to maintain their mental health, however, it has received no attention in the literature. Multimorbidity, known as the co-occurrence of two or more chronic conditions, have been suggested as another risk factor for mental health [18, 19] . It is becoming increasingly common and likely to increase progressively with age [20] . Accumulation of chronic conditions in older adults is a milestone for progressive loss of resilience and homeostasis [21] , thus, having multimorbidity may be not only physically challenging but also worsen mental health for older people during the COVID-19. We found no study have considered that the role of multimorbidity played in affecting mental health of older people who have transitioned into frail state during the COVID-19. In addition, one study have shown that new emerging multimorbidity is associated with more functional decline than pre-existing multimorbidity [22] , suggesting emerging multimorbidity and pre-existing multimorbidity may have the different effects on health among older people. Taken together, clarifying how the role of frailty transition and multimorbidity in changes of psychological distress during the COVID-19 pandemic has important implications for designing focused interventions to prevent and reduce psychological distress among older people. The present study aimed to assess the changes in psychological distress of older people before and during the COVID-19, and to evaluate the differential effects of frailty transitions and multimorbidity on the psychological distress during the COVID-19 pandemic. The present study used data from the Shandong Rural Elderly Health Cohort (SREHC). SREHC is an ongoing longitudinal study aiming at addressing ageing problems, targeted the population aged 60 and above in Shandong rural areas. Information collected in SREHC mainly includes a rich set of questions regarding demographics, socio-economic status, lifestyles, physical and psychological health of older people. Considering the potential poor vision of older adults, the questionnaires were read to the respondents by our interviewers. Completed questionnaires were carefully checked by quality supervisors at the end of each day. Psychological distress was assessed by Kessler Psychological Distress Scale (K10), which was a commonly used tool for screening mental health [23, 24] , and the reliability and validity of the K10 have been confirmed in China [25] . The scale evaluated the psychological distress of the respondents, including depression, anxiety, nervousness, hopelessness, restlessness, and worthlessness in the past four weeks. The scale contained 10-items and each item is scored from 1 (none of the time) to 5 (all of the time). The total score for the scale ranged from 10 to 50 points, the higher scores indicated the higher risk of psychological distress. Frailty status was measured by frailty phenotype criteria, which was proposed and validated by Fried et al. [12] . It consists of 5 items: shrinking (unintentional weight loss), weakness (grip strength), slowness (a walking time of 4.6 meters adjusted by gender and height), self-reported exhaustion, and self-reported low activity. Older people with 3-5 criteria were considered to be frail, 0-2 criteria were considered to be non-frail. In our study, frailty transition was defined as frailty status from a given state at baseline to another state at follow up, including from a given state to that the same state [26] . Thus, we classified the respondents into four frailty transition groups: (1) stable non-frail (who remained non-frail state during the survey period); (2) frailty progression (who transitioned from non-frail before the COVID-19 pandemic to frail state during the COVID-19 pandemic); (3) frailty recovery (who transitioned from frail before the COVID-19 pandemic to non-frail state during the COVID-19 pandemic); (4) stable frail. In this study, we defined multimorbidity as the co-existing of two or more chronic non-communicable diseases based on previous studies [27, 28] and the Chinese Centers for Disease Control and Prevention (CDC) recommendations [29] , including hypertension, diabetes, dyslipidemia, heart disease, asthma, stroke, cancer, chronic lung disease, digestive disease, liver disease, kidney disease, and arthritis. All chronic conditions were self-reported. To validate the accuracy of this information, the trained interviewers with medical knowledge would further ask the help from the village doctors to confirm the self-reported chronic condition information in the chronic disease case management system in the sampling villages. Then we categorized the progression of multimorbidity into three groups: no multimorbidity (no or on chronic condition reported), pre-existing multimorbidity (≥ 2 diseases reported at the baseline), and emerging multimorbidity (no or one disease reported at the baseline, but ≥ 2 diseases reported at the follow-up survey). We identified the potential confounders on the basis of the existing studies [ habits (whether the respondent was a daily tea drinker), sedentary behavior (hours/day), physical disability, and sleep quality. Physical disability was assessed by the activities of daily living (ADL) [18] , including bathing, dressing, using the toilet, continence, transferring and eating. We used the Pittsburgh Sleep Quality Index (PSQI) [31] to measure the sleep quality of the participants, and a total score of PSQI greater than 7 was classified as poor sleep quality [32] . First, all study variables were performed with a descriptive analysis. As the flow chart have shown in Fig. 1 , a total of 2785 older people who participated both the baseline and follow-up surveys were included in our study, with a response rate of 85.88% (2785/3243). Table 1 shows the participant characteristics at each wave of data collection. Of the 2785 respondents, the median age was 70 years, with a range from 60 to 100, 1770 were female (63.55%), and 1164 were illiteracy (41.80%). There were 40 older people with missing data not imputed. Older people completing the questionnaire (n = 2745) were more likely to be wealthier ( 2 = 10.25, P = 0.017), and non-frail ( 2 = 6.58, P = 0.010) than those who died (n = 42). Completers were also older than non-completers but younger than those who died (F = 3.78, P = 0.023). Of all frailty transitions, 11.91% constituted progression to a frail state, and 10.49% comprised recovery from a frail to a non-frail state. Regarding the multimorbidity progression, 36.18% had pre-existing multimorbidity before COVID-19, and 15.73% had new emerging multimorbidity during COVID-19 (Table 2) . The sensitivity analysis shows a consistent finding with the main analyses, that both frailty transition and multimorbidity were associated with increased psychological distress during COVID-19, and the association was particularly pronounced for the group of frailty progression who reported new emerging multimorbidity (Supplementary Table 1 ). Maintaining good mental health in older adults is crucial for their physical health and well-being [33] , especially during the pandemic of COVID-19 period [34] . [15] , plus the fear and worry resulted from the pandemic, lead to more psychological distress. Our finding also supports the frailty identity crisis, a hypothesis that characterize a psychological syndrome accompanying the transition from robust to frailty [39]. However, we found no association between frail to non-frail state and increased psychological distress, which reinforces the importance of intervention on frailty. Our findings underscore the negative effects and distinct prognostic value of certain frailty transitions. In other words, the dynamic nature of frailty transitions that we observed and the association of these dynamic changes with increased psychological distress during the COVID-19 pandemic suggest that promoting frailty recovery is critical to prevent or reduce psychological distress. This study also suggests that multimorbidity is associated with the increased psychological distress during the COVID-19, which is particularly more pronounced for older people who have reported new emerging multimorbidity than pre-existing multimorbidity. We sought to further determine whether frailty progression interact with emerging multimorbidity to predict increased psychological distress during the COVID-19 pandemic. Our results suggest that psychological distress has increased for This study also has several limitations. First, we assessed the chronic conditions using self-reported, which may result in some recall bias. Second, our longitudinal sample only included older people who completed the two waves, there might be possible selection bias associated with the attrition over the study. Third, this study was conducted only in rural older people, and whether the results are applicable to urban older people needs further study. In this prospective study, we found that the psychological distress has increased among the community-dwelling older adults during the COVID-19 pandemic. Sustained and progressive frail state, as well as multimorbidity were all associated with a greater increase of psychological distress during the COVID-19 pandemic, and the association between frailty progression and psychological distress was particularly pronounced for older people who reported new emerging multimorbidity. These findings suggest that future public health measures should take into account the increased psychological distress among older people, and the assessment of frailty and multimorbidity might help in warning of psychological distress. World Health Organization. Coronavirus disease 2019 (covid-19): Situation report-51 Chinese Center for Disease Control and Prevention. 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