Assessing Social Interaction and Loneliness and Their Association With Frailty Among Older Adults With Subjective Cognitive Decline or Mild Cognitive Impairment: Ecological Momentary Assessment Approach

Abstract

Background: Frail older adults are at greater risk of adverse health-related outcomes such as falls, disability, and mortality. Mild behavioral impairment (MBI), which is characterized by neurobehavioral symptoms in individuals without dementia, is a crucial factor in identifying at-risk groups and implementing early interventions for frail older adults. However, the specific role of social functioning, which encompasses social interaction and loneliness levels, in relation to frailty within this group remains unclear.

Objective: This study investigated the association between frailty status, social interaction frequency, and loneliness levels among older adults with subjective cognitive decline (SCD) or mild cognitive impairment (MCI) while adjusting for MBI symptoms in 2 contexts: the presence and severity of MBI symptoms.

Methods: Older adults with SCD or MCI were recruited from an outpatient clinic specializing in the early diagnosis and care management of dementia at a community health center, as well as from a community service center in Seoul, South Korea. Using an ecological momentary assessment approach, participants reported their daily social interaction frequency and loneliness level via a mobile app, 4 times daily for 2 weeks. Frailty status, the outcome variable, was assessed using the Korean version of the frailty phenotype questionnaire. Additionally, MBI symptoms were assessed using the 34-item MBI-Checklist covering 5 domains. Multinomial logistic regression analyses were performed to investigate the association between frailty status (robust, prefrail, and frail), and the independent variables, adjusting for the presence or severity of MBI symptoms.

Results: Among the 101 participants analyzed, 29.7% (n=30) of participants were classified as prefrail, and 12.8% (n=13) of participants were classified as frail. Higher average daily social interaction scores were consistently associated with lower odds of a frail status compared to a robust status. This was evident in the models adjusted for both the global presence (relative risk ratio [RRR] 0.18, P=.02) and global severity (RRR 0.20, P=.02) of MBI symptoms.

Conclusions: Frequent social interaction was inversely associated with frail status in older adults with SCD or MCI, even after adjusting for the presence and severity of MBI symptoms. These findings highlight the potential of social functioning as a modifiable factor for addressing frailty among older adults at risk of cognitive and functional decline. Future prospective studies using real-time measurements are needed to refine these findings and further investigate additional risk factors and functional outcomes in this group.

Keywords: Alzheimer; ageing; association; cognitive impairment; correlation; dementia; ecological momentary assessment; elderly; frailty; geriatric; interaction; isolation; lonely; mild behavioral impairment; older; psychogeriatrics; self-reported; social.

Figure 1

The proposed conceptual framework illustrates the relationship between frailty status, social interaction, and loneliness levels, while adjusting for the presence and severity of mild behavioral impairment symptoms among older adults with subjective cognitive decline or mild cognitive impairment. Based on the social-ecological model for older adults and the successful aging model proposed by Rowe and Kahn, individual determinants include sociodemographic characteristics, health status, and health behaviors. Social function, including daily social interaction frequency and daily loneliness level, is also considered. K-IADL: Korean Instrumental Activities of Daily Living scale.

Figure 2

Sequential steps involved in the recruitment and selection of study participants. We recruited 145 individuals aged ≥65 years from a dementia relief center or a community service center in Seoul, South Korea. The figure depicts the subdivision of these individuals into 3 groups: 58 with robust, 30 with prefrail, and 13 frail, based on specific inclusion and exclusion criteria. K-IADL: Korean Instrumental Activities of Daily Living scale; MBI: mild behavioral impairment.

Figure 3

The mobile app screens captured 2 questions that assessed daily social interaction frequency and loneliness levels. Daily social interaction frequency was measured by asking, “How many times did you interact with others, including face-to-face meetings, phone calls, or video calls lasting more than five minutes?” Responses were categorized into 5 options: no contact, once, twice, 3 times, and 4 or more times. Loneliness levels were measured by asking, “At this moment, how lonely do you feel?” Responses were also categorized into 5 options: very lonely, lonely, neutral, not lonely, and not lonely at all. Both questions were administered 4 times daily at specific intervals (upon waking and after breakfast, lunch, and dinner).

Figure 4

Distribution of average daily social interaction score and average daily loneliness level by frailty status. This figure displays the median levels and range variability of both average daily social interaction score and average daily loneliness levels among participants, categorized into robust, prefrail, and frail groups.

Figure 5

This figure shows the average predictive marginal effects of sociodemographic characteristics, health status, global MBI symptom presence, and social functioning on the probability of being classified as robust, prefrail, or frail. The predictive margins were calculated using multinomial logistic regression, with error bars representing 95% CIs for each effect. K-IADL: Korean Instrumental Activities of Daily Living scale; MBI: mild behavioral impairment; SCD: subjective cognitive decline.

Figure 6

This figure shows the average predictive marginal effects of sociodemographic characteristics, health status, global MBI symptom severity, and social functioning on the probability of being classified as robust, prefrail, or frail. The predictive margins were calculated using multinomial logistic regression, with error bars representing 95% CIs for each effect. K-IADL: Korean Instrumental Activities of Daily Living scale; MBI: mild behavioral impairment; SCD: subjective cognitive decline.