|Year : 2014 | Volume
| Issue : 2 | Page : 94-99
Does resilience affect illness perception and well-being in the elderly?
Shipra Singh, Pradeep Deshmukh, Apurva Ungratwar, Alka A Subramanyam, Ravindra Kamath
Department of Psychiatry, B. Y. L. Nair Charitable Hospital and TNMC, Mumbai, Maharashtra, India
|Date of Web Publication||3-Mar-2015|
Dr. Shipra Singh
Department of Psychiatry, B. Y. L. Nair Charitable Hospital and TNMC, Mumbai Central, Mumbai, Maharashtra
Source of Support: None, Conflict of Interest: None
Background: Increased life expectancy has increased many chronic illnesses in the elderly population, adding a phase of life affecting resilience, well-being, and perception of illness.
Aims and Objectives: To assess resilience, well-being, and illness perception in the elderly and study the relation among them.
Materials and Methods: A population of 90 (30 from the psycho-geriatric OPD, 30 from medical geriatric OPD and 30 normal elderly, accompanying patients in psycho geriatric OPD) patients age 60 years or more were taken, at a tertiary care center. Geriatric depression scale was applied and score <7 were selected for normal and rheumatoid arthritis. Patients with score >7 and fulfilling diagnostic and statistical manual-IV TR criteria were taken in depression group. Semi-structured proforma and scales (Connor Davidson resilience scale, Warwick Edinberg mental well-being scale, and brief illness perception scale) were applied, and statistical analysis was done using Statistical Package for the Social Sciences.
Results: Results demonstrated resilience (P < 0.001) significantly differed in the three groups. Resilience was higher in normal (P < 0.001) than rheumatoid arthritis, which is higher (P < 0.02) than depression group. Well-being also significantly differ in all three group (P < 0.001), higher in normal elderly (P < 0.001) than affected elderly. We found strong positive correlation between resilience and well-being.
Conclusion: Resilience is higher in those with a higher hardiness, optimism, purpose of life, and resourcefulness. Well-being gets significantly affected with mental and physical illness.
Keywords: Illness perception, resilience, well-being
|How to cite this article:|
Singh S, Deshmukh P, Ungratwar A, Subramanyam AA, Kamath R. Does resilience affect illness perception and well-being in the elderly?. J Geriatr Ment Health 2014;1:94-9
|How to cite this URL:|
Singh S, Deshmukh P, Ungratwar A, Subramanyam AA, Kamath R. Does resilience affect illness perception and well-being in the elderly?. J Geriatr Ment Health [serial online] 2014 [cited 2020 May 24];1:94-9. Available from: http://www.jgmh.org/text.asp?2014/1/2/94/152429
| Introduction|| |
"Resilience is accepting your new reality, even if it's less good than the one you had before. You can fight it, you can do nothing but scream about what you've lost, or you can accept that and try to put together something that's good."
Resilience is the capacity to maintain competent functioning in the face of major life stressors.  George Vaillant defines resilience as the "self-righting tendencies" of the person, "both the capacity to be bent without breaking and the capacity, once bent, to spring back."  It refers to the skills, abilities, knowledge, and insight that accumulate over time as people struggle to surmount adversity and meet challenges. 
Resilience involves an inference based on individual differences in response to stress or adversity. It seems to be an important factor in aging, since this is a period of life in which subjects need to cope with different stressful events, such as, the lack of personal autonomy, the decline in cognitive functions, and the augmented probability to cope with the death of significant others as well as their own.  With advanced age, the prevalence of physical diseases and impairments increases as do limitations in the ability to manage activities of daily living,  and high rates of depression have been reported. 
Wagnild and Young  identified five inter-related components that constitute resilience: Equanimity (a balanced perspective of one's life and experience); perseverance (a willingness to continue to reconstruct one's life and to remain involved); self-reliance (a belief in oneself and one's capabilities); meaningfulness (an understanding that life has a purpose); and existential aloneness (a realization that each person's life path is unique),  each of it having a distinct role in the process of good ageing.
The world is facing a growing population of older persons and, therefore, increasing incidence of functional disorders and chronic diseases with increasing age. US Census Bureau, International Data Base, 2004, reported 1000 million Indians or nearly 1 out of every 2 adults having at least one chronic disease. The most common chronic diseases are not directly fatal. This means that the person is ought to learn to live with a condition over an extended time course of years without the prospect of recovery. As such, living with a chronic disease imposes many threats and challenges to the person such as dealing with uncertainties about their present and future physical capacities, sustaining relationships with family and friends, dealing with pain and other symptoms, and concerns about their abilities to resume their former lifestyle. , The sustained and potential impact of these diseases, leading to individual morbidities and productivity loss, thus requires articulation of the possible factors at work in the etiopathogenesis and perpetuation of experiences in chronic illness.
Studies investigating life with chronic illness have identified themes like adjustments and adaptation and strength like resilience.  Coping, integral to illness and symptom management, is a function of these multiple interacting factors as they affect cognitive appraisal, behavioral response, and adjustment.  Living with chronic illness requires the ability to adapt to living with the stressors of unremitting symptoms, such as pain, fatigue, depression, and anxiety. While recovery is the desired outcome of illness, for those with chronic illnesses, the more attainable outcome may be that of maintained psychological and physiological well-being in the face of these chronic demands on fitness, a process of "stability through change" known as allostasis. 
Associations have been found between resilience and better general health health-related factors such as well-being, life satisfaction, ability to cope and adaptation. Foster  in his study, found that strong resilience has a protective effect against psychiatric morbidity; for example, it is related to a decreased risk of depression. Higher levels of resilience were associated with lower levels of depressive symptomatology and chronic pain, and with higher levels of mental and physical health. 
Resilience is quantifiable and influenced by status of health, that is, individuals with mental illness have lower levels of resilience than the general population.  But the resilience is distinct from "recovery," which involves regaining the equilibrium that existed prior to stress.  High hardiness and optimism are associated with better physiological, psychological, and spiritual well-being and buffer the effects of stress caused by chronic illness. ,
Common mental disorders like depression are strongly associated with disability and commonly influence an older person's ability to maintain personal care, housework, social activity, and ultimately well-being.  A link has also been established between the representation of the disease and the psychological well-being of patients with medical illness as well, like rheumatoid arthritis. 
There is a dearth of research on resilience in elderly  and relation to mental and medical disorders and more so, in Indian context. With this background, the aims were to study resilience and well-being in normal elderly subjects and patients with depression and rheumatoid arthritis; illness behavior in patients with depression and rheumatoid arthritis; and to find the relation among resilience, illness perception, and well-being.
| Materials and Methods|| |
It was a cross-sectional study carried out in the Psychiatry and Medicine OPD of a Tertiary Care Teaching Municipal Institute, after obtaining Institutional Ethics Committee approval. A total of 90 elderly with age of 60 years or more were included in study, 30 consecutive normal elderly people who accompanied patients attending psychiatry OPD, having geriatric depression scale (GDS) score <7; 30 consecutive elderly patient with depression attending psycho-geriatric OPD, having GDS score >7, but without medical co-morbidity; and 30 consecutive elderly patients with rheumatoid arthritis attending medical geriatric OPD, without psychiatric co-morbidity (GDS score <7). A written informed consent was taken from the participants before commencing the study. Interview was conducted by a single interviewer, using a semi-structured proforma, to capture the demographic and other details. In addition, the following three scales were applied.
The Connor-Davidson resilience scale
It consists of 25 questions, used to assess the resilience in all three groups. This scale was used to evaluate hardiness, optimism, purpose, and resourcefulness. These four factors were compared in the three groups. Cronbach's Alpha for the scale was 0.923, which is considered satisfactory. 
Warwick-Edinburgh mental well-being scale
This scale was used to assess mental well-being in all three groups by comparing the total scores. It comprises of 14 items that relate to an individual's state of mental well-being (thoughts and feelings) in the previous 2 weeks. Higher the score, higher is the mental well-being. Cronbach's alpha coefficient = 0.89 (n = 348). 
Brief illness perception questionnaire
This scale was used to assess illness perception in patients having depression and rheumatoid arthritis. Cognitive illness representations and emotional representations were compared amongst them. It contains nine items. All of the items except the causal question are rated using a 0-10 response scale. Five of the items assess cognitive illness representations: Consequences (item 1), timeline (item 2), personal control (item 3), treatment control (item 4), and identity (item 5). Two of the items assess emotional representations: Concern (item 6) and emotions (item 8). One item assesses illness comprehensibility (item 7). The psychometric properties have been previously tested on center-based HD patients, and the structural validity, internal reliability, test-retest reliability, and discriminant validity are within acceptable limits. The internal reliability for each of the five dimensions of the Brief illness perception questionnaire was demonstrated by Cronbach's alpha scores ranging from 0.70 to 0.75. ,
Descriptive statistics, Pearson's Chi-square test, One-way ANOVA, comparison by Holm-Sidak method and Pearson's correlation were used to analyze the variables, using Statistical Package for the Social Sciences version 20. P-value of less than 0.05 is taken to be significant.
| Results|| |
On assessing resilience, mean and standard deviation of different factors of resilience (hardiness, optimism, purpose, and resourcefulness) found are shown in [Table 1]. No significant difference was found based on age and gender, in any of the three groups (P > 0.05 on Mann-Whitney test). Comparing resilience among the three groups, as shown in [Table 1], a significant difference (P < 0.05) was found in all the four factors: Hardiness (P < 0.001), optimism (P < 0.001), purpose (P < 0.001), and resourcefulness (P < 0.001), as seen in [Table 2].
|Table 2: Difference in the various factors of resilience between various pairs of groups |
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Comparison of the various pairs suggests that hardiness was significantly more in normal group than depression (P < 0.001) and rheumatoid arthritis group (P < 0.001); however, it was more in rheumatoid arthritis group than depression (P = 0.012). Similar results were found for the factor for optimism. Normal elderly had significant differences for scales of "purposeful" and "resourcefulness;" although no significant difference was found between the groups of rheumatoid arthritis and depression.
On studying the well-being in the three groups, mean scores and standard deviations on WEMHS of normal elderly were found to be 54.03 ± 6.403, rheumatoid arthritis group 36.10 ± 7.613 and depression 32.63 ± 7.708. The difference among them was found to be significant using One-way ANOVA test (P < 0.001). Further studying the individual groups using pairwise multiple comparison procedures (Holm-Sidak method), well-being was more in normal elderly than depression (P < 0.001) and rheumatoid arthritis group (P < 0.001) but the latter two groups did not differ significantly, as shown in [Table 3].
On further analysis, the relationship between the well-being and various factors of resilience was worked out using the correlation technique, which is shown in [Table 4]. In the Normal Subjects, total resilience score correlated positively with well-being in normal elderly group, along with individual hardiness and purpose scales. In contrast, rheumatoid arthritis group showed a positive correlation between all the sub-scales of resilience and well-being (P = 0.000). In the group of depressed patients, there was a positive correlation between total resilience (P = 0.000) and sub-scales (hardiness, optimism, resourcefulness) with well-being.
|Table 4: Correlations between resilience total and individual scores with well-being |
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Finally, illness perception was assessed in patients having depression and rheumatoid arthritis, which showed no significant difference in the two groups on Mann-Whitney's test (P = 0.495). Relationship of illness perception with resilience was studied using Pearson's correlation, which shows that no significant correlation existed between total resilience or its sub-scales with illness perception in either of the two groups (depression and rheumatoid arthritis). However, the coefficient in each correlation was negative, which suggests that illness perception decreases, as resilience increases and vice-versa, although not statistically significant [Table 5].
| Discussion|| |
Resilience is the capacity to maintain competent functioning in the face of major life stressors. Living with chronic illness requires the ability to adapt to living with the stressors through resilience, which will impact well-being and illness perception.
The analysis of data from the study sample reveals that normal elderly are more resilient than patients with rheumatoid arthritis and depression. These elderly live their life with commitment, control, and challenge. They are more optimistic, have a sense of purpose in life and are resourceful. This finding is in accordance with previous study findings that resilience is quantifiable and influenced by health status. , The data directly linking resilience and rheumatoid arthritis are lacking but literature says resilience has been found to be negatively correlated with a range of poor mental and physical health conditions, such as increased depressive symptomatology, posttraumatic stress disorder, and physical disability. ,, Depressive symptoms such as withdrawal, loss of motivation, apathy, and physical disability may interfere with resilient processes in depressed older adults.  These findings may explain the decrease in resilience in chronic illness such as rheumatoid arthritis and depression in our study group.
Well-being in our study was found to be more in the normal group than those with rheumatoid arthritis and depression. Beekman et al.  also reported that depressive symptoms have considerable impact on the wellbeing and disability of older people. Study on rheumatoid arthritis by Nagyova et al.  found a similar result that rheumatoid arthritis patients demonstrate poorer psychological well-being.
Well-being showed significant positive correlation with resilience in all three group, which suggests that resilience leads to well-being or vice versa. However, impact of individual factors of resilience is not uniform.
Well-being in a depressed group (mean is 32.63) was lower than rheumatoid arthritis (mean is 36.10). This finding supports the observation of Hays et al.  on well-being has found that depressed patients have substantial and long-lasting decrements in multiple domains of functioning and well-being that equals or exceeds those of patients with chronic medical illnesses.
No statistical difference was found in perception of illness in patients with rheumatoid arthritis and depression.  It is estimated that depression occurs in 14-62% of rheumatoid arthritis patients.  This lack of difference may be due to exclusion of rheumatoid arthritis patients with psychopathology. The relationship between depression and chronic medical illness can often become a vicious circle.  We can conclude that the combined effect of both illnesses on illness perception in an individual may be higher than in individuals with either disorder alone.
Analysis of demographical variables like age, sex, financial dependence has not shown any difference in resilience. Mention in literature supports the finding that these factors do not exert long-term influence on resilience.  Resilience involves regaining the equilibrium that existed prior to stress. 
Therefore, a distinct correlation is seen between resilience and well-being in each group. Greater resilience and well-being were found among normal than those affected from medical and psychiatric morbidities. Elderly with chronic illnesses have shown more resilience and well-being than psychiatric illnesses.
| Conclusion and Implication|| |
It is well-evident that resilience is a factor that plays an important role in well-being of the elderly; although there was no significant difference in illness perception and well-being between patients having depression and rheumatoid arthritis. Patients with rheumatoid arthritis (i.e., chronic medical illness) were more optimistic about their illness and they view their illness with commitment, control and challenge than those having depression (i.e. chronic mental illness). A follow-up and interventional (programs to increase resilience) study would yield better results.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]