Regular Research Article
Complex Interplay Between Health and Successful Aging: Role of Perceived Stress, Resilience, and Social Support

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Psychological and psychosocial resources, including resilience and social support, have traditionally been studied in the context of the stress paradigm and, more recently, in the context of successful aging. This study used moderated mediation analyses to examine the role of perceived stress in the relationships between physical and mental health functioning and self-rated successful aging (SRSA) and whether differences between people in level of resilience and social support changes the role of perceived stress in these relationships. A cross-sectional study of 1,006 older adults (mean age: 77 years) completed scales addressing SRSA, physical and mental health functioning, perceived stress, resilience, and social support. Results indicated that the strength of relationships between both physical and mental health functioning and SRSA were reduced after accounting for variation in level of perceived stress. The role of perceived stress in the association between mental health functioning and SRSA was found to be stronger among participants with the highest levels of resilience, and the influence of perceived stress on the degree of relationship between physical health functioning and SRSA was stronger among those with greatest social support. These findings suggest that interventions to reduce perceived stress may help break the link between disability and poor well-being in older adults. The findings further suggest that the impact of such interventions might differ depending on psychological resources (i.e., resilience) for mental health disabilities and external resources (i.e., social support) for those with physical health problems. The complex interplay of these factors should be taken into account in clinical settings.

Introduction

Levels of physical health (PH) and mental health (MH) are important contributors to subjective well-being in late life. Successful aging is a way to conceptualize overall well-being in older adults and is no longer considered merely longevity or absence of disease or disability; rather, successful aging has been theorized to include various states of well-being with multiple determinants.1, 2 The National Institutes of Health identified a growing interest in patient-reported outcomes in PH and MH,3 and self-rated successful aging (SRSA) has been described as a meaningful way for individuals to assess and integrate the multidimensional components of their past, present, and future.2, 4 From a mechanistic perspective, the achievement of SRSA can be enhanced though the various pathways of health functioning.5 Indeed, several models of successful aging have been proposed involving complex associations between physical, cognitive, emotional, and psychosocial functioning. Doyle et al.’s model6 consists of objective and subjective components to successful aging, including physical function, activity, social engagement, and psychological traits, with particular emphasis on resilience and social engagement. Our research group previously found support for a model in which the level of SRSA was a downstream effect of the complex interactions between psychosocial protective traits (including resilience), PH, and MH.7 Another study found that positive psychological factors, such as resilience and self-efficacy, were predictive of future quality of life in older adults.8

The centrality of resilience (i.e., “ability to bounce back from the variety of challenges that can arise in life” [p. 1026])9 to many models of well-being among older adults raises the question of how stressful life events and individuals' responses to these events may play a role in successful aging. Unsurprisingly, high and/or chronic stress has been found to negatively influence well-being in older adults.10, 11, 12, 13 It has been suggested that perceived stress (i.e., subjective report of how stressful life situations are) has a bidirectional relationship with health and well-being outcomes such that perceived stress can lead to a decline in health and sense of well-being, and, conversely, health problems and a sense of poor well-being can cause one to appraise circumstances as exceptionally stressful.14 Additionally, it has been reported that health problems may only affect well-being and successful aging if a person perceives his or her health problems as stressful.15 Collectively, the literature suggests that PH and MH relate to subjective well-being in late life and points to a potential role of perceived stress in mediating these relationships, perhaps influenced by level of resilience and social support (i.e., the frequency of social interactions). To date, however, researchers have not considered the complex interrelationships between all these factors.

Building on previous research, the present study had three objectives. First, we investigated whether PH and MH were related to SRSA in a sample of older adults. Next, we examined whether or not the strength of these relationships would be changed by accounting for variation in levels of perceived stress. We hypothesized that perceived stress would serve an intermediary role between health and SRSA, thereby weakening the direct relationship between these factors. Such a finding would provide preliminary support for the notion that perceived stress is a pathway through which health affects well-being among older adults. We acknowledge that although some researchers believe mediation and moderation analyses cannot be done with cross-sectional data, we believe that despite inherent limitations, analyses with cross-sectional data provide useful information for future hypothesis-based longitudinal or intervention studies. Our final objective was to investigate the role of resilience and social support, both widely cited stress buffers, in the health→perceived stress→successful aging association. Specifically, we tested models examining the degree to which the potential influence of perceived stress on the strength of the association between health and SRSA might be altered depending on participants' level of resilience or social support. We expected among those with higher levels of resilience and social support that the strength of association between health and SRSA would be more diminished by accounting for simultaneous relationships of these measures with perceived stress.

Section snippets

Participants

This study was approved by the University of California, San Diego Institutional Review Board, and all participants provided written informed consent. One thousand six middle-aged and older adults participated in the Successful Aging Evaluation study. To study successful aging in a community-dwelling sample of adults living in San Diego county, the Successful Aging Evaluation study used a structured multicohort longitudinal design2; cross-sectional data from the first round of survey collection

Results

Summary statistics for participant clinical characteristics and correlations among study variables are presented in Table 1. All study variables were highly correlated, with a Bonferroni-adjusted critical value of p <0.003 to control for multiple comparisons (0.05/13 = 0.003), with the exception of the correlations between PH and social support and MH and social support. Of most relevance to our study goals, we found that individuals who reported worse PH and MH had lower SRSA.

Discussion

As hypothesized, the relationship between worse PH and MH functioning and lower well-being, as measured by SRSA, was weakened when associations between these factors and perceived stress were taken into account. This provides preliminary cross-sectional evidence that declines in PH and MH may lead to greater perceived stress, which in turn would decrease perceptions of well-being and successful aging. We found only partial support for the idea that levels of the potentially buffering variables

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