Archives of Gerontology and Geriatrics 67 (2016) 68–73

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Archives of Gerontology and Geriatrics

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Frailty and life satisfaction in Shanghai older adults: The roles of age
and social vulnerability
Fang Yang, PhDa,* , Danan Gu, PhDb , Arnold Mitnitski, PhDc
a
Department of Social Work, School of Sociology and Political Science, Shanghai University, A501, #99 Shangda Road, Baoshan District, Shanghai 200444,
China
b
United Nations Population Division, Two UN Plaza, DC2-1910, New York, NY, 20012, USA
c
Department of Medicine, Dalhousie University, Centre for Health Care of the Elderly—Suite 1305, 5955 Veterans’ Memorial Lane Halifax, Nova Scotia, B3H
2E1 Canada

A R T I C L E I N F O A B S T R A C T

Article history: Purpose: This study aims to examine the relationship between frailty and life satisfaction and the roles of
Received 17 February 2016 age and social vulnerability underlying the links in Chinese older adults.
Received in revised form 17 May 2016 Material and methods: Using a cross-sectional sample of 1970 adults aged 65 and older in 2013 in
Accepted 6 July 2016
Shanghai, we employed regression analyses to investigate the interaction between frailty and age on life
Available online 12 July 2016
satisfaction in the whole sample and in different social vulnerability groups. Life satisfaction was
measured using a sum score of satisfaction with thirteen domains. Using a cumulative deficit approach,
Keywords:
frailty was constructed from fifty-two variables and social vulnerability was derived from thirty-five
Frail elderly
Social vulnerability
variables.
Personal satisfaction Results: Frailty was negatively associated with life satisfaction. The interaction between frailty and age
Socioeconomic factors was significant for life satisfaction, such that the negative association between frailty and life satisfaction
Aged was stronger among the young-old aged 65–79 than among the old-old aged 80+. Moreover, frailty’s
stronger association with life satisfaction in the young-old than in the old-old was only found among
those in the 2nd and 3rd tertiles of social vulnerability, but not for those in the 1st tertile of social
vulnerability.
Conclusions: Relation between frailty and life satisfaction likely weakens with age. A higher level of
social vulnerability enlarges the negative impact of frailty on life satisfaction with a greater extent in the
young-old.
ã 2016 Elsevier Ireland Ltd. All rights reserved.

1. Introduction state characterized by decreased physical reserve in multiple

1.1. Frailty and life satisfaction
Life satisfaction represents a global evaluation of one’s life, and
is a very important component of subjective well-being (Diener,
Suh, Lucas, & Smith, 1999). Previous research has shown that
health factors (e.g., self-rated health and physical health) play a
significant role in life satisfaction and subjective well-being in
older adults (Cho, Martin, Margrett, Macdonald, & Poon, 2011;
Gana et al., 2013; Jonker, Comijs, Knipscheer, & Deeg, 2009).
Different from individual health indicators, frailty is a physiological
* Corresponding author.
E-mail addresses: ouyangfang2014@163.com, ouyangfang.pku@gmail.com
(F. Yang).
systems, which could lead to physiological dysregulation and
increased vulnerability to adverse outcomes (Fried et al., 2001;
Kulminski et al., 2006; Mitnitski et al., 2001). Among the diverse
operationalizations for frailty, frailty index based on the deficit
accumulation approach is widely used in the literature (Rockwood
& Mitnitski, 2007; Searle, Mitnitski, Gahbauer, Gill, & Rockwood
2008). Research shows that frailty index, incorporating a broader
range of psychological, physiological, and functional variables,
could serve as a good proxy for biological aging, and significantly
predicts a variety of outcomes, such as falls, hospitalization, and
mortality (Gu et al., 2009; Kulminski et al., 2006; Rockwood &
Mitnitski, 2007; Searle et al., 2008; Shi et al., 2011). However, much
less is known about the relationship between frailty and life
satisfaction in older adults.

http://dx.doi.org/10.1016/j.archger.2016.07.001
0167-4943/ã 2016 Elsevier Ireland Ltd. All rights reserved.
 F. Yang et al. / Archives of Gerontology and Geriatrics 67 (2016) 68–73
1.2. Role of age in the relationship between frailty and life satisfaction
Gerontological research suggests that the older adult popula-
tion is not a homogeneous group, instead there are two phases
with differing qualities in late adulthood, namely the third and the
fourth ages (Baltes, 1999; Baltes & Smith, 2003; Laslett, 1991).
Individuals in their third age (65–79), often referred to as the
young-old, are in the post-employment stage, mostly physically
and cognitively well functioning and are socially engaged in many
activities. However, individuals in their fourth age (80+), or the old-
old, often experience chronic conditions and health restrictions,
and face increasing limitations to their independence. Despite the
heterogeneity in each age group, limitations on activities of daily
living (ADL) and instrumental activities of daily living (IADL;
Krause & Hayward, 2012), cognitive decline (Salthouse, 2009), and
frailty (Gu et al., 2009) increase with age in general. These findings
imply that health restrictions or frailty might be more of a
normative phenomenon for the old-old than the young-old (Jopp &
Rott, 2006).
Even though the old-old experience more health constraints
than the young-old in general, the physical/health problems may
not necessarily impose a greater threat to their subjective
perceptions of life. Research shows that indicators of subjective
well-being remain relatively stable with age, despite increasing
physical and cognitive functioning decline in late adulthood
(Diener et al., 1999). There is plenty of evidence showing that the
old-old likely have a better strategy to adapt themselves to the
health restrictions than the young-old, thus reducing frailty’s
negative impact on subjective well-being (e.g., Jopp & Rott, 2006).
In addition, as frailty increases with age, it seems to be more
acceptable as an “on time” event among the old-old than the
young-old, and be less stressful than “off time” frailty that occurs
in the young-old (Wrosch & Heckhausen, 2005).
1.3. Role of social vulnerability in frailty * age and life satisfaction
In addition to frailty, numerous social factors also play a
significant role in older adults’ subjective well-being, such as
socioeconomic status, social support, social engagement, and
social capital (e.g., Andrew & Keefe, 2014). Different from
individual social factor, social vulnerability, referring to the
degree to which individuals’ overall social circumstances leave
them susceptible to adverse outcomes, would offer insights into
understanding the complex social situations older adults live in
and their health and well-being (Andrew & Keefe, 2014;
Armstrong et al., 2015). Social vulnerability could be constructed
using a deficit accumulation approach and combining a variety of
social factor into a single measure (Andrew & Rockwood, 2010).
Research shows that social vulnerability could predict cognitive
decline (Andrew & Rockwood, 2010) and mortality (Andrew,
Mitnitski, & Rockwood, 2008) in older adults. Moreover, a lower
level of social vulnerability, or better social circumstances could
enable individuals to better deal with stress (Andrew & Keefe,
2014), like frailty, thus to reduce the negative consequences of
frailty.
1.4. The present study
We focused on the older adults in Shanghai in this study.
Population aging is a worldwide social phenomenon and China
represents the largest elderly population in the world. According
to China National Bureau of Statistics, the population aged 65 and
above accounts for 10.1% of the total population by 2014 (National
Bureau of Statistics, China, 2015). Among the cities, Shanghai has
the nation’s largest proportion of older adults, and the percentage
of its elderly population (65+) has reached 18.8% by 2014
69
(Shanghai Research Center on Aging, 2015), which is almost
twice higher than that of the whole nation. In this sense, Shanghai
becomes an ideal place to examine older adults’ life satisfaction
and its correlates.
Despite that frailty is a prevalent phenomenon in older adults, it
is largely unknown about the relationship between frailty and life
satisfaction and whether such a relationship remains consistent
across different age groups and social vulnerability groups. To
address the gap in the literature, we aim to examine the
relationship between frailty and life satisfaction, and to explore
the role of age and social vulnerability underlying the relationship
in a representative sample of older adults in Shanghai, China.
2. Material and methods
2.1. Participants
We used the 2013 Survey of the Shanghai Elderly Life and
Opinion, which was conducted by the Shanghai Research Center on
Aging (SRCA). The survey utilized a stratified, multistage random
sampling design to reflect the age, gender, and rural/urban
structure of the local elderly population (see Feng et al., 2013;
for detailed information about the survey). Five districts in the
urban areas (e.g., Huangpu District) and five districts in the
suburban and rural areas (e.g., Minhang District) were randomly
selected first. Then four representative street residential commit-
tees in each selected urban district and three street residential/
rural residential committees in each selected suburban or rural
area were selected, with a total of 35 street residential/rural
residential committees included in the survey. Based on the roster
of the residents by age and gender of each selected site provided by
the local residential committee, a stratified random sample was
selected. One hundred people in each selected street residential/
rural residential committees were randomly selected and 3500
participants participated in the survey. The eligible participants for
the survey were those aged 50 or older with local household
registrations at the time of the interview. Respondents were
reached via the stress residential/rural committees with informed
consent. The final valid sample size was 3418 with a response rate
of 98%. All information was obtained via in-home interviews using
questionnaires by trained research assistants. Our current study
focused on respondents aged 65 and above with a sample of
N = 1970.
2.2. Measures
2.2.1. Life satisfaction
The life satisfaction was assessed by 13 items on participants’
subjective ratings. Sample items included “How satisfied are you
with your health status?” and “How satisfied are you with your
family relationships?” Each item was rated on a 5-point Likert scale
ranging from 1 = extremely satisfied to 5 = extremely unsatisfied.
Each item was reversely coded and then all the items were added
up, such that the composite scores, ranging from 13 to 65,
represent participants’ life satisfaction, with higher score denoting
a higher level of life satisfaction. The reliability of the scale in this
study was Cronbach’s a = 0.88, which is above the threshold of 0.70
for group comparisons and close to the threshold of 0.9 for
individual comparison as suggested by previous studies (Nunnally,
1994).
2.2.2. Frailty index
Previous studies often use multiple variables in various
dimensions to capture one’s cumulative health deficits (Gu
et al., 2009; Rockwood, Andrew, & Mitnitski, 2007; Searle et al.,
2008). Research using this approach does not necessarily include
70 F. Yang et al. / Archives of Gerontology and Geriatrics 67 (2016) 68–73

the same number or type of variables to assess frailty (Rockwood &
Mitnitski, 2007), and studies that selected different health-related
variables often yield comparable results (Rockwood, Mitnitski,
Song, Steen, & Skoog, 2006). In this study, we included 52
indicators in various domains to construct frailty index, including
self-reported health, cognitive functioning, disability in activities
of daily living and instrumental activities of daily living, and
chronic illnesses, and these items are similar to those used in
previous research (Gu et al., 2009; Mitnitski et al., 2001). Each
binary item was coded as 1 when a deficit was present and 0 when
a deficit was absent; and the options to continuous variables were
mapped onto the interval between 0 (if a deficit was absent) and 1
(if a deficit was present) (Rockwood, Andrew, & Mitnitski, 2007;
Searle et al., 2008). For example, the options to the question “How
often did you experience headache in the past 3 months?” were
based on a 5-likert scale from 1 = never, 3 = sometimes to 5 = always.
As such, never was coded as 0, sometimes as 0.5, and always as 1. The
value of the frailty index of each respondent was obtained by
summing up all values of deficits and dividing by the number of
variables under study (i.e., 52). The range of the frailty index score
was from 0 to 1, the higher the score, the higher level of frailty.
2.2.3. Social vulnerability index
Similar to frailty, social vulnerability was also measured using
cumulative deficit approach (Andrew et al., 2008). We used 35
indicators, including social support, marital status, education,
living arrangement, and leisure activities. These items were similar
to those used in previous research (Armstrong et al., 2015; Andrew
et al., 2008). Each respondent was assigned a score of 0 if a deficit
was absent and 1if it was present when the deficit was binary; and
continuous variables need grading the intermediate values into the
interval between 0 (if a deficit is absent) and 1(if a deficit is
present). For example, the options to the question “How often can
you find someone to take care of you when you are ill?” were based
on a 5-likert scale from 1 = never, 3 = sometimes to 5 = always. As
such, never was coded as 1, sometimes as 0.5, and always as 0. The
value of the social vulnerability index of each respondent was
obtained by summing up all values of deficits over these thirty-five
variables and dividing by 35. The social vulnerability index score
ranged from 0 to 1, with higher score denoting a higher level of
social vulnerability.
2.2.4. Covariates
Basic demographics including single year of age, gender and
urban/rural residence was entered in the analysis as covariates to
make the results more robust. The reason for treating gender and
urban/rural residence as covariates is the potential gender and
urban/rural residence differences in frailty (Gu et al., 2009), social
vulnerability (Andrew et al., 2008), and subjective well-being
(Diener et al., 1999).
2.3. Methods of analysis
Data analyses were conducted using SPSS version 20. In order to
examine the interaction between frailty and age on life satisfaction,
we divided the sample into two age groups: the young-old (65–79)
and the old-old (80+). We first provided descriptive statistics of the
whole sample and for each age group, followed by linear regression
analyses with covariates controlled for to examine the interaction
between frailty and age on life satisfaction. Continuous variables
(i.e., frailty index and social vulnerability index) were mean-
centered in the regression. Given the potential role of social
vulnerability, we further examined the interaction between frailty
and age on life satisfaction across three tertiles of the social
vulnerability index.
2.4. Ethical approval
Ethics approval was obtained from Shanghai University (IRB-
2016NO.01).
3. Results
3.1. Sample characteristics
The mean age of the participants in the current study was 75.2
years old (SD = 7.57), the older adults aged 65–79 accounted for
71.5% of the sample, and males accounted for 46% (Table 1). In
addition, the majority of the participants were currently married
(69.5%), lived in the urban areas (87.1%), and received 1+ year of
schooling (83.9%). The distributions of these factors for two large
age groups were also shown in Table 1. The means of frailty index
and the social vulnerability index in the young-old were lower than

Table 1
Descriptive Statistics for the Key Variables: Total Sample and by Age Group.

Total (N = 1970) Young-old (N = 1409) Old-old (N = 561) Differences

Mean of Age (SD) 75.17(7.57) 71.24(4.44) 85.04(3.96) t(1968) = 67.36, p < 0.001
Mean of Frailty index (SD) 0.21(0.15) 0.18(0.12) 0.30(0.18) t(1968) = 14.98, p < 0.001
Mean of Social vulnerability index (SD) 0.15(0.09) 0.14(0.09) 0.18(0.09) t(1968) = 8.20, p < 0.001
Gender (percentage)
Male 46.00% 48.80% 39.00% p < 0.001a
Female 54.00% 51.20% 61.00%
Marital status
Married 69.50% 87.40% 44.40% p < 0.001a
Others 30.50% 20.40% 55.60%
Urban/rural residence
Urban 87.10% 87.40% 86.50% p = 0.585a
Rural 12.90% 12.60% 13.50%
Education
No schooling 16.10% 10.30% 30.70% p < 0.001a
Schooling 83.90% 89.70% 69.30%
Occupation
White collar 24.90% 28.70% 15.30% p < 0.001a
Others 75.10% 71.30% 84.70%
Living arrangement
Living alone 13.50% 11.00% 19.60% p < 0.001a
Others 86.50% 89.00% 80.40%
a
Note: p values were obtained from the chi-square tests.
 F. Yang et al. / Archives of Gerontology and Geriatrics 67 (2016) 68–73
those in the old-old. Moreover, the distributions of the factors
(gender, marital status, education, occupation, and living arrange-
ment), except the urban/rural residence, were different between
the two age groups.
3.2. Regression results for life satisfaction
Results in Table 2 show that the old-old were more likely to
report higher life satisfaction than their young-old counterparts
(B = 1.34, p < 0.001) when controlling for other factors that
influence life satisfaction, including frailty and social vulnerability.
Moreover, frailty was negatively associated with life satisfaction
(B = 23.85, p < 0.001). In addition, the interaction between frailty
and age was also significant (B = 5.17, p = 0.011) (see Table 2).
Further tests show that the negative relationship between frailty
and life satisfaction was stronger among the young-old than the
old-old, which suggests that frailty might impose a stronger
impact on the young-old’s life satisfaction than that of the old-old.
3.3. The role of social vulnerability index
The interaction of frailty and age on life satisfaction across the
tertiles of the social vulnerability index was presented in Table 3.
Results show that the interaction between frailty and age on life
satisfaction was only significant in the 2nd and 3rd tertiles of the
social vulnerability index (B = 7.88, p = 0.021; B = 8.31, p = 0.033,
respectively), but not in the 1st tertile of the social vulnerability
index (B = 3.71, p = 0.354). The significant interactions of frailty
and age on life satisfaction in the 2nd and the 3rd tertiles of the
social vulnerability index demonstrated similar patterns to the
previous significant interaction, in other words, the negative
relationship between frailty and life satisfaction was stronger
among the young-old than the old-old. The findings also suggest
that lower social vulnerability or better social circumstances the
elderly live in might buffer the greater impact of frailty on life
satisfaction for the young-old.
4. Discussion
By examining the relationship between frailty and life
satisfaction, the current study offered insights into understanding
the complex picture of frailty and life satisfaction. We found that
frailty was negatively related to life satisfaction, and the negative
relationship between frailty and life satisfaction was stronger in
the young-old than in the old-old. In addition, the interaction
between frailty and age on life satisfaction was significant only in
socially more vulnerable groups, but not in the top one-third social
advantageous group.
As expected, we found that frailty, representing cumulative
health deficits in various domains, was a negative correlate of life
satisfaction, which supports our hypothesis. Our finding is in line
Table 2
Linear Regression Results of Life Satisfaction.
Variables B 95% CIs Std Error
Male (vs female) 0.31 ( 0.87, 0.25) 0.28
Urban (vs rural) residence 0.86* (-1.67, 0.04) 0.42
Social vulnerability index 34.17*** (-37.38, 30.97) 1.63
Old-old (vs young-old) 1.34*** (0.67, 2.00) 0.34
Frailty index 23.85*** (-26.67, 21.03) 1.44
Frailty index x Old-old 5.17* (1.18, 9.16) 2.04
Constant 50.05*** (49.22, 50.87) 0.42
R2 35.80%
Note: B = unstandardized coefficient, b= standardized coefficient, CI = confidence
interval; in the regression, social vulnerability index and frailty index were mean-
centered. *p < 0.05. **p < 0.01. ***p < 0.001.
71
with previous research showing that health decline and lower
perceived health were associated with a significant decrease in life
satisfaction (Gwozdz & Sousa-Poza, 2010; Jonker, Comijs, Knipsch-
eer, & Deeg, 2009). Even though there are other factors that could
impact older adults’ life satisfaction, health factor imposes a
substantial influence, especially for the older adults who are
experiencing health decline in general.
Moreover, our study extended the literature by empirically
demonstrating differential impacts of frailty on life satisfaction in
different age groups in late adulthood. These findings echo with
similar ideas elucidated in previous research. For example, Jopp
et al. (2008) found that the role of health factors in valuation of
life–the results of cognitive-affective evaluation–was much
stronger for the young-old than for the old-old, and this perception
might further impact individuals’ subjective evaluation of their
aging experiences. In addition, research also suggests that the
relations between the changes in subjective well-being and the
changes in functional aspect mainly occur earlier in the aging
process, and these relations weaken with age (Werngren-Elgstrom,
Carlsson, & Iwarsson, 2009). There are several explanations for the
age differential relationships. First, as discussed before, the “off-
time” nature of frailty at a point in life during which the young-old
are finally freed from the influence of work and pursue a sense of
meaning and passion might have a stronger impact for this
population. However, for the old-old, frailty tends to be seen as
rather normative, and they may have adapted to the health
constraints and tend to be less adversely affected by frailty (Jopp
et al., 2008). Second, relating to previous point, the age-related
adaptation process may play a role. As life satisfaction is the overall
evaluation of one’s life in general, despite the decline in the health
domain, the old-old can still remain satisfied with life utilizing
adaptive coping strategies, such as reorientation of goal priories
and regulation of social relationship (Boerner & Jopp, 2007; Lang,
2001; Saajanaho et al., 2016). Given that frailty imposes a greater
threat to life satisfaction for the young-old, more attention should
be paid to this population.
Regarding the role of social vulnerability, results show that the
stronger negative association between frailty and life satisfaction
in the young-old than in the old-old was only found in the 2nd and
3rd tertiles of the social vulnerability index, that is, poorer social
circumstances. In other words, good social circumstances buffer
the stronger impact of frailty on life satisfaction in the young-old.
The findings highlight the importance of considering social
circumstances older adults live in when examining older adults’
subjective appraisals of their aging experiences. Furthermore,
social vulnerability is a multidimensional concept including levels
from individual, close family, social network to community, and
the social ecological perspective of social vulnerability could
inform health professionals or social workers in cases of “social
admissions” (Andrew & Keefe, 2014; Theou & Rockwood, 2015).
Among the various social factors, some of them are subject to
change, and interventions or policies could target those modifiable
factors at each level.
There are several limitations that should be noted in this study.
First, the cross-sectional nature of the study cannot substantiate
b the causality among the variables. Future research with a
0.02
longitudinal design using life-course theory is needed to better
0.04* delineate the temporary order of the variables. Second, this study
0.39*** focused on the elderly in Shanghai, China, and the findings of the
0.08*** study might not be generalized to other populations in other cities
0.46***
of China or other cultural contexts. Third, the variables included in
0.07*
the social vulnerability index are limited to a small set of variables.
Prior research has suggested that the factors included in social
vulnerability could be more diverse and even include community-
level SES (Andrew & Keefe, 2014). However, the existing
information of the survey (e.g., lack of community-level SES)
72 F. Yang et al. / Archives of Gerontology and Geriatrics 67 (2016) 68–73

Table 3
Linear Regression Results of Life Satisfaction for Study Variables across Social Vulnerability Index Groups.

1st tertile of SVI 2nd tertile of SVI 3rd tertile of SVI

Variables B 95%CIs SE b B 95%CIs SE b B 95%CIs SE b

Malea 0.10 ( 0.80,0.99) 0.45 0.01 0.4 ( 1.31,0.51) 0.46 0.03 0.35 ( 1.48,0.79) 0.58 0.02
Urbanb 0.07 ( 1.66,1.52) 0.81 0.01 0.66 ( 1.90,0.59) 0.63 0.04 1.32 ( 2.86,0.23) 0.79 0.06
Old-oldc 0.78 ( 0.40,1.95) 0.6 0.05 1.90*** (0.85,2.95) 0.54 0.14*** 0.58 ( 0.71,1.86) 0.65 0.04
Frailty index 21.99*** ( 26.42, 17.57) 2.25 0.43*** 26.96*** ( 31.58, 22.35) 2.35 0.60*** 24.51*** ( 30.47, 18.55) 3.04 0.5***
Frailty index X Old-old 3.71 ( 11.56,4.14) 4 0.04 7.88* (1.17,14.60) 3.42 0.12* 8.31* (0.66,15.96) 3.9 0.14*
Constant 52.32*** (50.74,53.73) 0.81 50.25*** (49.02,51.48) 0.63 47.21*** (45.65,48.78) 0.8
R2 19.80% 24.10% 14.90%

Note: The dependent variable of the regression is life satisfaction. Frailty index was mean-centered. B = unstandardized coefficient, b = standardized coefficient, SE = standard
error, SVI = social vulnerability index. *p < 0.05, **p < 0.01, ***p < 0.001.
a
Reference category is female.
b
Reference category is rural residence.
c
Reference category is the young-old.

limited such investigation. It would benefit in the future research
to expand the set of social factors to better elucidate the role of
social vulnerability. In addition, the accuracy of some information
(e.g., symptoms in the past 3 months) may be subject to older
adults’ recall bias, and it would be better to use respondent’s pre-
existing medical records if possible. Lastly, we only focused on a
few variables that predict life satisfaction. Research shows that
there are other important factors that could influence life
satisfaction, such as personality and community-level factors
(Diener et al., 1999). Future research is needed to include more
variables to gain a better understanding of the correlates of life
satisfaction.
5. Conclusions
Despite the limitations, the current study examined the
relationship between frailty and life satisfaction and explored
the role of age and social vulnerability in a representative sample of
older adults in Shanghai. Frailty has a differential impact on life
satisfaction in the older adults, with a stronger negative impact in
the young-old than in the old-old. Moreover, such a relationship
was only found for those with higher social vulnerability. Future
intervention might target frailty and social circumstance the
elderly live in to improve older adults’ subjective well-being.
Conflict of interest
The authors declare that they have no competing interests.
Acknowledgement
Dr. Fang Yang’s work was supported by a grant from Shanghai
Municipal Education Commission “Chenguang Scholar Program”
(15CG46) that was awarded to her.
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