General self-efficacy and frailty in hospitalized older patients: The mediating effect of loneliness

For older adults with chronic diseases, it is not the disease itself that is important, but the patient's geriatric syndrome. The risk of frailty is greatly increased in older adults with chronic diseases due to degenerative physiological changes and complex and variable diseases, which in turn increases the susceptibility to various adverse outcomes, delays recovery and increases the risk of rehospitalization, ultimately creating a vicious circle.1 This not only causes physical suffering to older patients with chronic diseases, but also seriously affects their psychological health. However, it is worth mentioning that psychological health problems are clinical manifestations of frailty and important predictors of frailty in older patients with chronic diseases. Certainly, solely focusing on the physical components of frailty can lead to a lack of holistic care.2

As an important psychosocial variable in clinical psychology, self-efficacy has a direct impact on health according to the social cognitive theory proposed by Bandura.3 Self-efficacy is the overall self-confidence that an individual displays in response to challenges in certain situations.4 In addition to affecting the individual's behavioral, cognitive and emotional processes, self-efficacy has also effect on the body's physiological responses in the stress network, which is crucial for psychological and physical health.5 Interestingly, self-efficacy can be modulated. The improvement of self-efficacy can enhance psychological regulation, relieve psychopathological symptoms, and is considered to be an important factor in improving health behavior in clinical settings. A growing number of scholars have also recognized this and suggested that general self-efficacy was associated with frailty and might be a key factor in frailty intervention.6,7 Hladek et al.8 found that older adults with low self-efficacy were at higher risk of frailty compared to those with high self-efficacy, and suggested that the relationship between general self-efficacy and frailty should be further investigated and the potential mediating variables between the two considered.

The outbreak of COVID-19 has been posing a huge challenge to health system. With hospital administrations issuing "strict entry and exit" visitation system, the psychological problems of hospitalized older patients have come to the fore, and loneliness has now become another psychological variable that needs our urgent attention. Loneliness often brings about a series of physical and psychological health problems, which is the response of the discrepancy between the individual's expectation of reaching the level of social contact and reality.9 Apart from causing older patients to be prone to psychological problems such as anxiety and depression, loneliness also reduces the patient's ability on daily living activities, and is even associated with the development of frailty.10 According to a longitudinal study, high levels of loneliness can lead to an increased risk of frailty, which may be related to the fact that loneliness could change the neuroendocrine activities, immune system, and induce cardiovascular and other diseases, eventually promote the onset of frailty.11 Some researchers discussed that sociodemographic variables, social support and physical health variables could be used to construct predictive models for loneliness in older adults. However, they also pointed that self-efficacy was a more important and stronger predictor of loneliness in older adults.12

In conclusion, these studies support the importance of general self-efficacy for frailty and the possibility that loneliness mediates the relationship between general self-efficacy and frailty. In the context of global aging and the COVID-19,13,14 attention to general self-efficacy and loneliness in hospitalized older patients with chronic diseases is crucial for medical staff to develop interventions to delay frailty. Therefore, this study aimed to examine the effect of general self-efficacy on frailty in hospitalized older patients with chronic diseases and the mediating role of loneliness in the relationship between general self-efficacy and frailty.

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