Structural, Biological, and Psychosocial Determinants of Frailty in Community-dwelling Older Adults in the U.S.

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2023

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Abstract

Frailty is a common geriatric syndrome in older adults associated with a host of adverse outcomes. Frailty disproportionately affects women, older adults who identify as Hispanic, non-Hispanic Black, and those with less income in the US. The underlying mechanism contributing to frailty disparities across structural social determinants of health (gender, race, ethnicity, and education) is poorly understood. This study aimed to elucidate whether these structural social determinants operate through intermediary biological factors (cardiometabolic) and psychosocial stressors and influence frailty in community-dwelling older adults in the US. The World Health Organization’s conceptual framework of action on social determinants of health (CSDH) underpins this study. The CSDH framework claims that structural social determinants of health shape social hierarchy contingent on individuals’ gender, race, ethnicity, and education, which may offer structural advantages and disadvantages. Individuals’ ranking in the social hierarchy may differentially expose them to intermediary health-promoting or damaging factors leading to disparate health outcomes. This study hypothesized that structural social determinants (gender, race, ethnicity, and education) are associated with disproportionate exposure to intermediary biological cardiometabolic factors and psychosocial stressors, which may be related to the differential frailty risk. This cross-sectional, descriptive, correlational study is the secondary analysis of the existing data from the Health and Retirement Study (HRS). This study involved approximately 8000 older adults (65 years and above) who met the eligibility criteria for the examination of physical, cardiometabolic biomarker measurements, and psychosocial information in 2006 or 2008. We used the Fried phenotype to classify frailty on the basis of the presence of at least three features, such as poor grip strength, slow gait speed, fatigue, weight loss, and low physical activity. We used clinical cutoffs to dichotomize the presence and absence of seven cardiometabolic factors (elevated blood pressure, sugar, C-reactive protein, total cholesterol; obesity, abdominal obesity, and low high-density lipoprotein). Based on empirical studies, we dichotomized six psychosocial factors (loneliness, financial strain, perceived everyday discrimination, subjective social status, poor neighborhood, and experience of traumatic life events) originating from multiple life domains into high and low psychosocial stressors. We used latent class analysis to identify subgroups of older adults with distinct combinations of cardiometabolic (typologies). Path analysis (a series of logistic regressions) was used to examine the structural determinants and cardiometabolic relationships with frailty and explore whether cardiometabolic typologies mediate the relationship between structural determinants and frailty. Our results further confirm that frailty disparities persist. Female, older adults who identify as Hispanic, non-Hispanic Black, and those with less education had a higher frailty risk relative to male, non-Hispanic White older adults, and those with high education. Structural social determinants were significantly related to latent subgroups of older adults with distinct cardiometabolic typologies. The members of the insulin resistance subgroup were more likely to be female, they were more likely identify as non-Hispanic Black, and were college non-graduates. The members of the hypertensive dyslipidemia were more likely to identify as non-Hispanic other minorities and were high school graduates, and the members in the hypertensive subgroup were more likely to be male and college graduates. The frailty risk differed among these latent subgroups of older adults, and the insulin resistance subgroup had a higher frailty risk than hypertensive dyslipidemia and hypertensive subgroups. In contrast, the frailty risk did not differ in the latter two subgroups. However, cardiometabolic typologies did not mediate the relationship between structural social determinants and frailty. Cumulative psychosocial stress was used to assess co-occurring psychosocial stress stemming from multiple life domains. We measured cumulative psychosocial stress by counting six dichotomized psychosocial stressors originating from multiple life domains. Path analysis (a series of multivariable regression models) was used to examine structural social determinants and cumulative psychosocial stress relationships with frailty and determine the mediating role of cumulative psychosocial stress between structural social determinants and frailty. Older adults who identified as Hispanic, non-Hispanic Black, non-Hispanic other ethnic minorities, and those with less education were more likely to experience greater cumulative psychosocial stress. Greater cumulative psychosocial stress was associated with higher frailty risk; however, it did not mediate the relationship between structural social determinants and frailty. Our results solidify the multifactorial nature of frailty. Structural social determinants, cardiometabolic typologies, and cumulative psychosocial stress independently contributed to frailty. Surprisingly, cardiometabolic typologies and cumulative psychosocial stress did not mediate the relationships between structural social determinants and frailty. Our study sets the foundation for exploring other biological and psychosocial stressors contributing to frailty and examining their mediating roles.

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Shakya, Shamatree (2023). Structural, Biological, and Psychosocial Determinants of Frailty in Community-dwelling Older Adults in the U.S. Dissertation, Duke University. Retrieved from https://hdl.handle.net/10161/27633.

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