This paper is in the following e-collection/theme issue:

Mental Health Issues in Elderly Patients and Geriatric Psychiatry (82) JMIR Theme Issue: COVID-19 Special Issue (2390) Preventing Social Isolation and Fostering Social Interactions in Old Age (55) Anxiety and Stress Disorders (1005) Outbreak and Pandemic Preparedness and Management (1674) Infectious Diseases (non-STD/STI) (1484) Research Instruments, Questionnaires, and Tools (540)

Published on in Vol 4, No 2 (2021): Apr-Jun

Preprints (earlier versions) of this paper are available at https://preprints.jmir.org/preprint/25876, first published .
Gender Differences in State Anxiety Related to Daily Function Among Older Adults During the COVID-19 Pandemic: Questionnaire Study

Gender Differences in State Anxiety Related to Daily Function Among Older Adults During the COVID-19 Pandemic: Questionnaire Study

Gender Differences in State Anxiety Related to Daily Function Among Older Adults During the COVID-19 Pandemic: Questionnaire Study

Authors of this article:

Sara Rosenblum1 Author Orcid Image ;   Ortal Cohen Elimelech1 Author Orcid Image
Article Authors Cited by (8) Tweetations (2) Metrics

    Original Paper

    The Laboratory of Complex Human Activity and Participation, Department of Occupational Therapy, University of Haifa, Haifa, Israel

    Corresponding Author:

    Sara Rosenblum, PhD

    The Laboratory of Complex Human Activity and Participation

    Department of Occupational Therapy

    University of Haifa

    Mount Carmel

    Haifa, 31905

    Israel

    Phone: 972 4 8240474

    Email: rosens@research.haifa.ac.il


    Background: The COVID-19 pandemic poses a challenge to people’s day-to-day functioning and emotional and physical health, especially among older adults.

    Objective: The aim of this study is to analyze gender differences in state anxiety, daily functional self-actualization, and functional cognition as well as the relationships among those factors in older adults during the COVID-19 pandemic lockdown.

    Methods: We collected data on the web from a sample of 204 people (102 men and 102 women) aged 60 years and older. In addition to a demographic questionnaire, we used the State-Trait Personality Inventory to assess state anxiety, the Daily Functional Actualization questionnaire to evaluate daily functional self-actualization, and the Daily Living Questionnaire to measure functional cognition.

    Results: Significant gender differences were found for state anxiety (t202=−2.36, P=.02); daily functional self-actualization (t202=2.15, P=.03); and the functional cognition components: complex tasks (Z=−3.07, P=.002); cognitive symptoms that might be interfering (Z=−2.15, P=.028); executive functions (Z=−2.21, P=.024); and executive function monitoring (Z=−2.21, P=.027). Significant medium correlations were found between both state anxiety level and daily functional self-actualization (r=−0.62, P<.001) and functional cognition (r=0.37-0.40, P<.001). Gender predicted 3% of the variance in state anxiety level, while daily functional self-actualization predicted 41% and complex activities (Daily Living Questionnaire) predicted an additional 3% (F3,200=58.01, P<.001).

    Conclusions: In older adults, anxiety is associated with cognitive decline, which may harm daily functional abilities and lead to social isolation, loneliness, and decreased well-being. Self-awareness and knowledge of gender differences and relationships between common available resources of daily functional self-actualization and functional cognition with anxiety may be strengthening factors in crisis periods such as the COVID-19 pandemic.

    JMIR Aging 2021;4(2):e25876

    doi:10.2196/25876

    Keywords

    COVID-19; coronavirus; anxiety; cognition; aging; eHealth; online data 


    Background

    The COVID-19 pandemic poses a challenge to people's day-to-day functioning and constitutes a meaningful factor related to their emotional and physical health [1,2]. Expansion of the disease, reports of illness and death, and social isolation, especially during lockdown, may lead people to feel sadness, depression, and anxiety and to decrease their daily functioning [3,4]. Among older adults, this situation is especially worrisome. Anxiety disorders and symptoms have been found to be the most widespread mental disorders among this population, even when not in crisis periods. Further, such disorders and symptoms may worsen physical resistance and disease in older adults [5,6].

    Within the literature, some studies have focused specifically on mental health of older adults during the COVID-19 pandemic crisis. These studies evidenced increased depression symptoms and anxiety stress among older persons, with higher levels of distress found among women [7-9]. For example, approximately 12% of 7127 older adults in a survey conducted in the United Kingdom from May to July 2020 reported feeling worse depression and anxiety levels during the COVID-19 lockdown; of those reporting worse depression and anxiety, 17% were women, while only 7.8% were men [7]. Gustavsson and Beckman [9] reported significantly higher frequency of decreased mental health among older women than among men of the same ages, such as feeling bad due to isolation, experiencing worries (about health, the economic situation, and implications to society), having sleeping problems, and feeling depressed. Casagrande et al [8] and Robb et al [7] summarized that older women had increased risk for higher levels of distress and anxiety compared to older men.

    Although these findings described the mental health status of older adults during the COVID-19 pandemic, there remains a general lack of literature about gender-related relationships between mental health, specifically anxiety levels and daily function characteristics. In routine periods, interrelationships were described between satisfying daily function and cognitive functioning with aging well and lower anxiety levels among older persons [10-12]. Older people who were active, satisfied with their daily function, and had no cognitive limitations interrupting their daily function achieved better mental health, including the lowest anxiety [11]. On the other hand, studies found associations among older adults between declined or unsatisfactory functional abilities loss of control and decreased physical and mental health [13]. Because gender differences were reported as prominent in mood and anxiety disorders [14], this factor must be considered when analyzing daily function as it relates to anxiety.

    Crisis periods especially increase the importance of discovering mechanisms that enable people to maintain or achieve good, durable mental health. Thus, this study focuses on analyzing state anxiety as it relates to two further concepts that reflect older adults’ daily functioning: (1) daily functional self-actualization and (2) functional cognition. State anxiety is defined as a temporary emotion characterized by feelings of tension and increased autonomic nervous system functions in situations experienced as a threat and that continues as long as the situation is interpreted to be a threat [15]. Teixeira et al [16] reported higher levels of state anxiety among women ages 62-93 in routine times (eg, not during crises such as the COVID-19 pandemic) than among men of the same ages.

    Maslow [17] described self-actualization in his 1954 hierarchical motivation theory as individuals’ expression of their full potential and desire for self-fulfillment. His growth-focused actualization model emphasized individual strengths towards a growth-oriented approach rather than a pathology-oriented approach focused on individuals’ deficiencies [18]. In this study, we consolidated the Maslow self-actualization theory [17] with concepts of daily functional self-actualization based on the World Health Organization (WHO) International Classification of Functioning, Disability, and Health (ICF) concepts [19]. The WHO established the ICF as a model of health and disease management linking health-related issues with individuals’ capacities, daily activity performance, and participation and environmental factors. Health-related issues include physical and psychological conditions that affect a person's daily functional abilities and vice versa. Thus, satisfying daily functioning can lead to improved sense of control, homeostasis, and better health [20]. Combining Maslow's self-actualization theory with the ICF classification concepts and further literature (eg, [21,22]) enabled us to assume that if individuals are satisfied with their daily doing (activities and participation as related to their environmental expectations [19]) and feelings of mastery and competence while achieving their full potential [17], then they may feel less anxiety due to loss of life control and more self-fulfilled despite the COVID-19 crisis. Thus, self-actualization related to daily doing—that is, daily functional self-actualization—may be a source of strength for older adults during crises. However, as far as we know, no previous study has reported gender differences related to this concept, likely due to the absence of a practical standardized instrument to measure them. Consequently, although previous results indicated significant relationships between either daily functional abilities or individuals’ self-fulfillment and health and well-being (eg, [21,22]), relationships between daily functional self-actualization and state anxiety among older people have not been studied, or at least have not been reported.

    A further aspect analyzed in the current study in the context of searching for strengthening factors is functional cognition. Functional cognition refers to the application of cognitive skills to self-care and community living. Life consists of a process of daily cognitive problem-solving requirements that are essential to efficiently accomplish daily activities. Efficient performance can engender feelings of daily occupational satisfaction [23]. The cognitive ability to perform routine tasks and complex everyday activities entails functional cognition [24]; thus, functional cognition is properly evaluated in the context of actual task performance. It includes individuals’ capacity to perform tasks and considers their abilities as a whole, including habits, routines, and environmental resources [24].

    Beyond the differences related to anxiety that prior studies have reported, our review of the literature revealed that gender differences in daily functional self-actualization or in functional cognition have not been described among older adults during crisis periods.

    Research Aims

    Considering the possible implications of daily functional self-actualization on anxiety and health, recognizing gender differences and understanding relationships among these concepts may supply insight into each gender’s unique needs. This may then provide opportunities to improve both older adults’ well-being in crisis periods and stakeholders’ awareness. As such, this study aimed to analyze gender differences related to state anxiety, daily functional self-actualization, and functional cognition, as well as the relationships among those factors, in older adults during the COVID-19 pandemic lockdown. We hypothesized that (1) significant gender differences would be found in state anxiety, daily functional self-actualization, and functional cognition; (2) significant correlations would be found among state anxiety, daily functional self-actualization, and functional cognition for the entire sample; and (3) gender, daily functional self-actualization, and functional cognition would predict state anxiety for the entire sample.


    Participants and Procedure

    The data were collected from 204 people (102 men and 102 women) aged 60 years and older between September 20 and October 10, 2020—a period when the respondents were in lockdown due to the COVID-19 pandemic. The data were gathered using an Israeli survey company, Panel4, that specializes in recruiting and incentivizing participants for web-based research (eg, in exchange for gift certificates). Panel4 can provide 400,000 panel members recruited via advertisements on Google, Facebook, and other popular websites, thus representing the adult population in Israel for web-based research. Ours was a sample of those panelists who chose to participate in response to our call distributed by the company among their members. Participants completed a demographic questionnaire and the instruments detailed in the following sections anonymously and independently on the web (via a link to the Qualtrics platform).

    Instruments

    State Anxiety: State-Trait Personality Inventory

    State anxiety was measured by the State-Trait Personality Inventory (STPI) [25], a 10-item inventory that assesses the respondent’s specific pattern of emotions, such as anxiety, anger, depression, and curiosity. Participants rate their present agreement with the items on a 5-point Likert-type scale from 1 (not at all) to 5 (very much). Higher scores indicate greater state anxiety (CD Spielberger, G Jacobs, R Crane, et al, 1979, Preliminary manual for the State-Trait Personality Inventory (STPI), University of South Florida, unpublished manuscript). In this study, the STPI internal consistency was high (.71), which is consistent with previous studies [5,25]. Moreover, the STPI has been found to have good reliability and validity among older adults [26].

    Daily Functional Self-Actualization Questionnaire

    The Daily Functional Self-Actualization Questionnaire (DailyFA) was developed by the authors within a short time in response to the need to measure daily self-actualization during the COVID-19 lockdown period. Based on the Maslow theory [17], the ICF concepts [19], and the first author’s rich clinical experience, results of studies among the aging population (eg, [20,27-29]) and development of 11 assessment tools, the first author chose 10 items for the questionnaire. These items as derived from both the ICF [19] and Maslow theory [17] (see Figure 1) related to physical and emotional health, sense of control over life, satisfaction from daily doing, self-fulfillment, environmental factors, and quality of life. Content and face validity were established based on literature reports about self-actualization and daily function. Expert validity was further established by four occupational therapy researchers, who agreed that the items are appropriate to cover the construct of daily functional self-actualization and that each item was clearly articulated. Participants rated their fulfillment or satisfaction with each item on a 10-point scale from 1 (not good at all) to 10 (very good). The DailyFA indicated a high level of internal consistency (α=.94) in this study.

    ‎
    Figure 1. The 10 items of the Daily Functional Actualization questionnaire, derived from both the International Classification of Functioning, Disability, and Health [19] and Maslow’s theoretical concepts [17].
    View this figure
    Functional Cognition: Daily Living Questionnaire

    In this study, we measured functional cognition using the self-report Daily Living Questionnaire (DLQ), which relates to cognitive difficulties in activities and participation as well as to cognitive components such as memory, executive functions, and executive function monitoring [27]. The DLQ assesses everyday difficulties in activities and participation tied with higher level cognitive deficiency. It includes 51 daily activities within 2 domains. The first domain, Part A (28 items), relates to activities and participation and consists of 4 factors: household tasks, activities involving language/comprehension, community/participation, and complex tasks. The second domain, Part B (24 items), relates to cognitive symptoms or impairments and consists of 3 factors: executive function, memory, and executive function monitoring. Using a 4-point Likert-type scale from 1 (no mental or cognitive difficulty) to 4 (unable to complete), respondents rate their level of mental or cognitive difficulty when performing activities. The DLQ content and face validity were established, and it was found to have an acceptable internal consistency for both parts. Furthermore, validity has been demonstrated by distinctions between age groups and between participants with multiple sclerosis and controls [20]. The internal consistency for this study was high for all 52 items (α=.94) and for each part separately (α=.87 for Part A; α=.94 for Part B).

    Data Analysis

    Descriptive statistics were used to describe the sample. The demographic gender variables (woman and man) were compared using chi-square tests, t tests for independent variables, and Mann-Whitney tests. Between-group differences in state anxiety, daily functional self-actualization, and functional cognition were examined using t tests for independent variables and Mann-Whitney tests. To examine the prediction of state anxiety by gender, daily functional self-actualization (DailyFA mean score), and functional cognition (DLQ factors), we conducted stepwise regressions, with gender inserted at the first phase and DailyFA and DLQ variables afterward.


    Sociodemographic Characteristics

    The sample included 204 Jewish adults living in Israel. Most spoke Hebrew (94/102 women, 92.2%; 96/102 men, 94.1%) and lived in a city (94/102 women, 92%; 84/102 men, 82%). As presented in Table 1, the participants’ sociodemographic characteristics indicated no significant gender differences for age, years of education, place of birth, main language spoken, place of residence, or religious affinity. However, significantly fewer female than male participants were married (with or without children) or were retired. No significant correlations were found between marital status or being retirement and any of the main research variable scores (eg, state anxiety, daily functional self-actualization, or functional cognition factors). Thus, those sociodemographic characteristics were not retained as covariates in the later gender-comparison analyses.

    Table 1. Participants’ sociodemographic characteristics by gender (N=204).
    Sociodemographic characteristicWomen (n=102)Men (n=102)χ2 (df)P value
    Age (years), mean (SD)69.01 (0.58)69.28 (0.59)0.33a (202).74
    Education (years), mean (SD)13.6 (0.44)13.69 (0.42)0.09 (201.69).93
    Years since retirement, mean (SD)11.28 (7.57)10.64 (9.15)−0.98b.32
    Place of birth, n (%)9.05 (6).17

    		Israel72 (70.6)63 (61.8)


    		Europe8 (7.8)19 (18.4)


    		United States1 (1.0)1 (1.0)


    		Asia6 (5.8)1 (1.0)


    		Africa5 (4.9)5 (4.9)


    		Former Soviet Union6 (5.8)8 (7.8)


    		Other4 (3.9)5 (4.9)

    Marital status, n (%)25.27 (4)<.001

    		Single5 (4.9)5 (4.9)


    		Separated or divorced28 (27.5)8 (7.8)


    		Married with or without children59 (42.2)88 (69.2)


    		Widowed10 (9.8)1 (1.0)

    Religious affinity, n (%)5.65 (3).13

    		Secular75 (73.5)71 (69.9)


    		Religious2 (2.0)9 (8.8)


    		Ultra-orthodox1 (1.0)0 (0)


    		Traditional24 (23.5)22 (21.6)

    Employment status, n (%)2.82 (1).09

    		Usually working46 (45.1)58 (56.9)


    		Not usually working56 (54.9)44 (43.1)

    Retirement, n (%)6.72 (1).01

    		Yes30 (29.4)48 (47.1)


    		No72 (70.6)54 (52.9)

    at test.

    bMann-Whitney test.

    Gender Differences: Hypothesis 1

    State Anxiety

    Independent t tests showed significant group differences for state anxiety based on STPI score. The female participants had significantly higher mean state anxiety scores than the male participants (female: mean 24.98, SD 7.98; male: mean 22.44, SD 7.31; t202=−2.36, P=.02).

    Daily Functional Self-Actualization

    Independent t tests revealed that during the COVID-19 crisis period, the female participants had significantly lower mean DailyFA scores than the male participants (female: mean 6.06, SD 1.96; male: mean 6.64, SD 1.94; t202=2.15, P=.03), indicating lower daily functional self-actualization for the women. The means and standard deviations for each DailyFA item are presented in Table 2.

    Table 2. Gender comparison of means and standard deviations of the DailyFA questionnaire items and final mean scores.
    DailyFAa itemScore, mean (SD)

    		Women (n=102)Men (n=102)
    1. Satisfied with physical health7.37 (2.13)7.06 (1.94)
    2. Self-actualization in work/academy6.01 (2.85)6.70 (2.63)
    3. Satisfies the ability to perform what ought to do6.58 (2.90)6.83 (2.36)
    4. Satisfies the ability to perform what you wish to do5.51 (2.55)5.71 (2.51)
    5. Quality of life6.01 (2.19)6.74 (2.09)
    6. A sense of control over your life5.82 (2.42)6.47 (2.51)
    7. Self-fulfillment5.10 (2.53)5.85 (2.65)
    8. Physical environmental resources enabling desired doing5.67 (2.52)6.27 (2.51)
    9. Human environmental resources enabling desired doing5.95 (2.61)6.58 (2.42)
    10. Mood in routine6.24 (2.50)6.97 (2.07)
    Total mean score6.03 (1.97)6.65 (1.94)

    aDaily FA: Daily Functional Actualization questionnaire.

    Functional Cognition

    As presented in Table 3, the Mann-Whitney analysis showed that women reported significantly more cognitive difficulties while performing both community-related and complex tasks. They also reported higher cognitive symptoms that might be interfering with daily performance on the whole DLQ, on the Part B score, and on each of its components (executive function, memory, and executive function monitoring).

    Table 3. Gender comparison of the mean scores and standard deviations of the DLQ factors.
    DLQa factorScore, mean (SD)ZP value


    		Women (n=102)Men (n=102)

    Part A: Activities and participation1.56 (0.46)1.54 (0.52)−8.13.43

    		1. Household task1.29 (0.38)1.46 (0.57)−1.66.11

    		2. Activities involving language/comprehension1.54 (0.54)1.52 (0.62)−0.76.45

    		3. Community/participation1.75 (0.71)1.69 (0.61)−1.01.35

    		4. Complex task1.74 (0.71)1.49 (0.61)−3.07.002
    Part B: Cognitive symptoms that might be interfering1.54 (0.52)1.41 (0.49)−2.15.03

    		1. Executive function1.62 (0.58)1.47 (0.56)−2.21.02

    		2. Memory1.43 (0.55)1.44 (0.64)−1.65.08

    		3. Executive function monitoring1.46 (0.52)1.33 (0.45)−2.21.03

    aDLQ: Daily Living Questionnaire.

    Correlations: Hypothesis 2

    Spearman correlations yielded significant correlations between state anxiety and both the daily functional self-actualization score on the DailyFA (r=−0.62) and some functional cognition factors on the DLQ (complex task: r=0.37; executive function: r=0.37; and executive function monitoring: r=0.40), with P values of <.001 for all 4 variables.

    Predictors of State Anxiety: Hypothesis 3

    Tables 4 and 5 present the stepwise regression analysis, which indicates that gender contributed 3% to anxiety prediction. Daily functional self-actualization accounted for 41% of anxiety prediction, and the functional cognition subscale, complex activities, accounted for an additional 3%. Thus, 47% of the state anxiety variability was predicted by gender, daily functional self-actualization, and complex activities (F3,200=58.01, P<.001).

    Table 4. Predicting state anxiety from gender, daily functional self-actualization, and functional cognition.
    ValueModel 1Model 2Model 3

    		B (SE)βP valueB (SE)βP valueB (SE)βP value
    Gendera2.59 (1.07).16.021.03 (0.82).07.21b0.67 (0.82).04.41
    Daily functional actualization (DailyFA)cN/AN/AN/A–2.55 (0.21)–.65<.001–2.33 (0.22)–.60<.001
    Complex activities (DLQ)dN/AN/AN/AN/AN/AN/A1.98 (0.64).17.002

    aGender 1=female.

    bN/A: not applicable.

    cDFA: Daily Functional Actualization questionnaire.

    dDLQ: Daily Living Questionnaire.

    Table 5. F and R values of the statistical analysis predicting state anxiety from gender, daily functional self-actualization, and functional cognition.
    ValueModel 1Model 2Model 3
    F change5.57a148.09b9.57c
    R2 (adjusted R2)0.03 (0.02)0.44 (0.43)0.47 (0.46)
    R2 change0.030.410.03

    aP=.02

    bP<.001.

    cP=.002


    Principal Results

    This study aimed to evaluate gender differences related to the state anxiety, daily functional self-actualization, and functional cognition of older adults during the COVID-19 lockdown period and to search for relationships among those factors. The results show significant gender differences in all three areas and significant correlations between state anxiety and both daily functional self-actualization and some functional cognition components. Further, 47% of the state anxiety variability was predicted by gender (3%) and both daily functional self-actualization (41%) and the complex activities subscale of the DLQ measuring functional cognition (3%).

    Gender Differences

    Anxiety is associated with cognitive decline and may harm daily functional abilities, which in turn can lead to loneliness and decreased well-being [5,30]. The results show significantly higher state anxiety levels among women during the pandemic period. These findings are supported by previous studies conducted in the United Kingdom [7], Italy [8], and Sweden [9], which presented significantly more negative feelings—including anxiety—among women than among men. Similarly, the significant gender differences found in daily self-actualization, which represents people's resources and feelings related to their daily function, are supported by studies that focused on gender differences in functional capacity and abilities in routine periods and not during crises such as the COVID-19 pandemic. These studies found gender differences in actual daily performance. However, they did not measure daily functional self-actualization in routine periods or in the COVID-19 pandemic period. Thus, a comparison of these results with previous studies is limited. The earlier findings included a study by Potvin and colleagues [26], which reported that women over the age of 65 years had significantly lower scores on performance-based functional capacity tests.

    Gender differences have also been found in activities of daily living and instrumental activities of daily living performance among people aged 82 to 87 years [31]. Pachana and colleagues [31] noted that despite a higher incidence of chronic conditions among women, the female participants in their study reported significantly less difficulty preparing meals, taking medications, using the telephone, and performing leisure activities than the male participants. However, the women reported having significantly greater difficulty with shopping and housework activities compared to the partnered men.

    Some difficulties performing such activities may relate to decreased executive functions. Executive functions are a set of cognitive skills that are necessary to plan, monitor, and execute a sequence of goal-directed complex actions [32]. Decreases in those abilities need to be identified in a timely fashion because they may influence daily functional performance abilities [33]. For example, Coppin and his colleagues found an association between poorer executive function and lower gait speed among older adults [34]; this may serve an important marker for decreases that may be associated with both physical and mental health. Interestingly, when focusing on functional cognition, the results of this study indicate significantly more functional cognitive difficulties for women in “complex tasks” and in cognitive components, such as executive function and executive function monitoring. However, these results did not hold for other kinds of tasks, such as household tasks (as also reported by Pachana and colleagues [31]) or for activities involving language and community/participation. It is noteworthy that Pachana and colleagues [31] reported a higher incidence of chronic conditions among women. It would be interesting to study the possible associations between difficulty performing complex daily tasks—which are cognitively demanding and require massive decision-making and thus demand daily energy—and women’s physical and mental health status. Analysis of a more comprehensive model that considers possible moderators and mediators variables is required.

    Indeed, difficulties performing daily tasks in older adults may be tied with emotional, physical, or cognitive deficits [28]. Specifically, our results show significant inferior cognitive symptoms that may be interfering in daily function (eg, in the executive function and executive function monitoring of the DLQ Part B) among women. Similar to the results of this study, earlier studies showed that women older than 65 years and living in the community exhibited lower cognitive performance on the Mini-Mental State Examination (MMSE) than men in the same circumstances [35,36]. In contrast to our results, McCarrey and colleagues [37]—who used the MMSE and other neuropsychological tests—reported decreasing executive function abilities with age and greater resilience to age-related cognitive decline in older women than in older men. In the same line, in their comprehensive review of studies of gender comparisons related to executive functions, Grissom and Reyes [38] presented no gender differences in executive function as measured by neuropsychological tests. The MMSE is designed to screen for cognitive decline, and it (or similar neuropsychological tests) may not reflect real-world functional cognition [39]. These opposing results related to older adults’ abilities in specific cognitive components suggest a reminder that our study focused on functional cognition. From an ecological viewpoint, life becomes more complex and demanding over the years. Among older adults, especially in late life, extensive impairment of daily functioning may occur due to cognitive decline [40]. Indeed, measuring cognitive difficulty levels when performing varied tasks adequately reflects such reduction in daily life functioning [20]. Consequently, further studies are required to determine whether the significantly inferior executive function and executive function monitoring found in our research among women is due to the use of a cognitive functional self-report scale or caused by the crisis period, which may have more influence on the women’s functional behavior.

    Relationships Among State Anxiety, Daily Functional Self-Actualization, and Functional Cognition

    The question of relationships among functional cognition, daily functional self-actualization, and state anxiety—especially in crisis periods—is of interest toward better understanding and possible prevention. The significant correlations found in our study are supported by previous studies. For instance, earlier studies found that women with generalized anxiety disorder presented higher degrees of functional impairment [41,42]. Although better cognitive performance has been found to be a protective factor among older adults [43], anxiety can cause an increase in cognitive dysfunction [44]. Prior research also associated community-dwelling older adults who showed higher state anxiety with worse learning, memory, and executive function abilities [45,46]. A long-term longitudinal study among twins over the age of 50 years reported a bidirectional relationship between anxiety symptoms and certain cognitive abilities, including processing speed and attention [23]. Additional cognitive performance, such as visuospatial ability and immediate and delayed memory, have also been found to be significantly associated with both state and trait anxiety among healthy older adults [47].

    Predictors of State Anxiety

    The results of significant gender differences in state anxiety achieved particular significance in light of the regression analysis results indicating that gender indeed contributed to state anxiety prediction. Both results emphasize the importance of considering gender as a factor that plays a role in dealing with stressful events and relates to the mental health of older persons in challenging periods as the COVID-19 pandemic.

    The finding in this study that daily functional self-actualization predicts 41% of state anxiety, and that specific aspects of functional cognition (eg, complex activities) predict another 3% is particularly interesting. Positive effects were previously reported between cognitive functioning and mild and moderate state anxiety among older people in routine times [12]. Knowledge of these relationships between anxiety and the common available resources of daily functional self-actualization and functional cognition related to gender differences, potentially obtainable in part through self-awareness and self-reflection, seems to play an important role in participation. Satisfactory participation in daily life activities promotes well-being and increases individuals’ sense of purpose and meaning [48]. The level of interest, value, and personal causation in everyday activities [46], especially leisure, social, and physical activities, has been associated with life satisfaction and psychological well-being among older adults [49-54]. For instance, Soderhamn et al [30] conducted interviews among 11 adults aged 67 years and older to grasp the meaning of self-care actualization (eg, activities that improve, maintain, or restore health). They found that self-care, as well as the use of self-care resources to care for others, was meaningful due to the sense of control over life and the self-reflection and realization it provides [30]. We surmise that the use of web-based self-report questionnaires (such as the DLQ and DailyFA used in this study) may be a resource to achieve such self-reflection. If so, the use of web-based self-report questionnaires may enhance self-awareness, psychological autonomy, life control, health, and well-being [20,55,56].

    Limitations and Future Research

    The results of this study should be interpreted in the context of several limitations. First, the DailyFA questionnaire was developed to address the urgent need to measure daily functional self-actualization during the COVID-19 lockdown period; more research is required to further establish the validity and reliability of the scale. Second, it was not our aim to compare precrisis and postcrisis results. Because anxiety and functioning may be correlated in general (and not specifically in relation to the COVID-19 pandemic), further studies are required to compare features in routine precrisis periods to features during the crisis to determine whether these study results depend upon the crisis period or reflect a global phenomenon among older adults. Third, we did not explore the potential effects of self-reflection that may have arisen as participants completed the web-based self-report questionnaires. Future studies should explore the effects of such questionnaires on respondents’ well-being.

    Conclusions

    Without doubt, late life is a challenging period associated with forfeiture and changes in physical, emotional, and social domains. Recognizing a person’s resiliency resources while focusing on functional abilities in conjunction with mental health may help older adults turn adverse events into opportunities and increase personal growth and life satisfaction [57]. Physical and mental health status is essential for people to perceive their personal strengths, while psychological resources may help them deal with physical and mental impairments and new circumstances, such as the COVID-19 crisis [44].

    Acknowledgments

    This study was supported by the Ministry of Science and Technology, Israel.

    Conflicts of Interest

    None declared.

    References

    1. Pieh C, Budimir S, Probst T. The effect of age, gender, income, work, and physical activity on mental health during coronavirus disease (COVID-19) lockdown in Austria. J Psychosom Res 2020 Sep;136:110186 [FREE Full text] [CrossRef] [Medline]
    2. Rothan HA, Byrareddy SN. The epidemiology and pathogenesis of coronavirus disease (COVID-19) outbreak. J Autoimmun 2020 May;109:102433 [FREE Full text] [CrossRef] [Medline]
    3. Cao W, Fang Z, Hou G, Han M, Xu X, Dong J, et al. The psychological impact of the COVID-19 epidemic on college students in China. Psychiatry Res 2020 May;287:112934 [FREE Full text] [CrossRef] [Medline]
    4. Tull MT, Edmonds KA, Scamaldo KM, Richmond JR, Rose JP, Gratz KL. Psychological outcomes associated with stay-at-home orders and the perceived impact of COVID-19 on daily life. Psychiatry Res 2020 Jul;289:113098 [FREE Full text] [CrossRef] [Medline]
    5. Petkus AJ, Reynolds CA, Wetherell JL, Kremen WS, Pedersen NL, Gatz M. Anxiety is associated with increased risk of dementia in older Swedish twins. Alzheimers Dement 2016 Apr;12(4):399-406 [FREE Full text] [CrossRef] [Medline]
    6. Lim W, Liang C, Assantachai P, Auyeung TW, Kang L, Lee W, et al. COVID-19 and older people in Asia: Asian Working Group for Sarcopenia calls to actions. Geriatr Gerontol Int 2020 Jun;20(6):547-558 [FREE Full text] [CrossRef] [Medline]
    7. Robb CE, de Jager CA, Ahmadi-Abhari S, Giannakopoulou P, Udeh-Momoh C, McKeand J, et al. Associations of social isolation with anxiety and depression during the early COVID-19 pandemic: a survey of older adults in London, UK. Front Psychiatry 2020;11:591120 [FREE Full text] [CrossRef] [Medline]
    8. Casagrande M, Favieri F, Tambelli R, Forte G. The enemy who sealed the world: effects quarantine due to the COVID-19 on sleep quality, anxiety, and psychological distress in the Italian population. Sleep Med 2020 Nov;75:12-20 [FREE Full text] [CrossRef] [Medline]
    9. Gustavsson J, Beckman L. Compliance to recommendations and mental health consequences among elderly in Sweden during the initial phase of the COVID-19 pandemic–a cross sectional online survey. Int J Environ Res Public Health 2020 Jul 26;17(15) [FREE Full text] [CrossRef] [Medline]
    10. Halaweh H, Dahlin-Ivanoff S, Svantesson U, Willén C. Perspectives of older adults on aging well: a focus group study. J Aging Res 2018;2018:9858252 [FREE Full text] [CrossRef] [Medline]
    11. Losada A, Márquez-González M, Pachana NA, Wetherell JL, Fernández-Fernández V, Nogales-González C, et al. Behavioral correlates of anxiety in well-functioning older adults. Int Psychogeriatr 2015 Jul;27(7):1135-1146. [CrossRef] [Medline]
    12. Potvin O, Bergua V, Meillon C, Le Goff M, Bouisson J, Dartigues J, et al. State anxiety and cognitive functioning in older adults. Am J Geriatr Psychiatry 2013 Sep;21(9):915-924. [CrossRef] [Medline]
    13. Lee Y. The predictive value of self assessed general, physical, and mental health on functional decline and mortality in older adults. J Epidemiol Community Health 2000 Feb;54(2):123-129 [FREE Full text] [CrossRef] [Medline]
    14. Altemus M, Sarvaiya N, Neill Epperson C. Sex differences in anxiety and depression clinical perspectives. Front Neuroendocrinol 2014 Aug;35(3):320-330 [FREE Full text] [CrossRef] [Medline]
    15. Hamann DL. An assessment of anxiety in instrumental and vocal performances. J Res Music Educ 2016 Aug 19;30(2):77-90. [CrossRef]
    16. Teixeira CM, Vasconcelos-Raposo J, Fernandes HM, Brustad RJ. Physical activity, depression and anxiety among the elderly. Soc Indic Res 2012 Jun 19;113(1):307-318. [CrossRef]
    17. Maslow A. Motivation and Personality. New York, NY: Harper & Row; 1954.
    18. Collins M. Spiritual intelligence: evolving transpersonal potential toward ecological actualization for a sustainable future. World Futures 2010 Jul 08;66(5):320-334. [CrossRef]
    19. International Classification of Functioning, Disability and Health (ICF). World Health Organization. 2001.   URL: https://www.who.int/classifications/icf/en/ [accessed 2021-05-20]
    20. Rosenblum S. Towards daily function homeostasis: a conceptual health framework and keys for action. J Fam Med Dis Prev 2017 Jun 30;3(2):A. [CrossRef]
    21. Steger MF, Kashdan TB, Oishi S. Being good by doing good: daily eudaimonic activity and well-being. J Res Pers 2008 Feb;42(1):22-42. [CrossRef]
    22. Håkansson C, Björkelund C, Eklund M. Associations between women's subjective perceptions of daily occupations and life satisfaction, and the role of perceived control. Aust Occup Ther J 2011 Dec;58(6):397-404. [CrossRef] [Medline]
    23. Petkus AJ, Reynolds CA, Wetherell JL, Kremen WS, Gatz M. Temporal dynamics of cognitive performance and anxiety across older adulthood. Psychol Aging 2017 May;32(3):278-292 [FREE Full text] [CrossRef] [Medline]
    24. Giles GM, Edwards DF, Baum C, Furniss J, Skidmore E, Wolf T, et al. Making functional cognition a professional priority. Am J Occup Ther 2020;74(1):7401090010p1-7401090010p6 [FREE Full text] [CrossRef] [Medline]
    25. Ben-Zur H, Zeidner M. Sex differences in anxiety, curiosity, and anger: A cross-cultural study. Sex Roles 1988 Sep;19(5-6):335-347. [CrossRef]
    26. Potvin O, Bergua V, Meillon C, Le Goff M, Bouisson J, Dartigues J, et al. Norms and associated factors of the STAI-Y state anxiety inventory in older adults: results from the PAQUID study. Int Psychogeriatr 2011 Aug;23(6):869-879. [CrossRef] [Medline]
    27. Rosenblum S, Josman N, Toglia J. Development of the Daily Living Questionnaire (DLQ): a factor analysis study. Open J Occup Ther 2017 Oct 01;5(4):A. [CrossRef]
    28. Rosenblum S, Engel-Yeger B, Fogel Y. Age-related changes in executive control and their relationships with activity performance in handwriting. Hum Mov Sci 2013 Apr;32(2):363-376. [CrossRef] [Medline]
    29. Rosenblum S, Werner P, Dekel T, Gurevitz I, Heinik J. Handwriting process variables among elderly people with mild Major Depressive Disorder: a preliminary study. Aging Clin Exp Res 2010 Apr;22(2):141-147. [CrossRef] [Medline]
    30. Söderhamn U, Dale B, Söderhamn O. The meaning of actualization of self-care resources among a group of older home-dwelling people--a hermeneutic study. Int J Qual Stud Health Well-being 2013 Apr 19;8:1-9 [FREE Full text] [CrossRef] [Medline]
    31. Pachana NA, McLaughlin D, Leung J, McKenzie SJ, Dobson A. The effect of having a partner on activities of daily living in men and women aged 82-87 years. Maturitas 2011 Mar;68(3):286-290. [CrossRef] [Medline]
    32. Royall DR, Lauterbach EC, Cummings JL, Reeve A, Rummans TA, Kaufer DI, et al. Executive control function: a review of its promise and challenges for clinical research. A report from the Committee on Research of the American Neuropsychiatric Association. J Neuropsychiatry Clin Neurosci 2002 Nov;14(4):377-405. [CrossRef] [Medline]
    33. Engel-Yeger B, Rosenblum S. Executive dysfunctions mediate between altered sensory processing and daily activity performance in older adults. BMC Geriatr 2021 Feb 22;21(1):132 [FREE Full text] [CrossRef] [Medline]
    34. Coppin A, Shumway-Cook A, Saczynski JS, Patel KV, Ble A, Ferrucci L, et al. Association of executive function and performance of dual-task physical tests among older adults: analyses from the InChianti study. Age Ageing 2006 Nov;35(6):619-624 [FREE Full text] [CrossRef] [Medline]
    35. Sposito G, Neri AL, Yassuda MS. Advanced Activities of Daily Living (AADLs) and cognitive performance in community-dwelling elderly persons: data from the FIBRA Study - UNICAMP. Rev Bras Geriatr Gerontol 2016 Feb;19(1):7-20. [CrossRef]
    36. Kim M, Park J. Factors affecting cognitive function according to gender in community-dwelling elderly individuals. Epidemiol Health 2017;39:e2017054 [FREE Full text] [CrossRef] [Medline]
    37. McCarrey AC, An Y, Kitner-Triolo MH, Ferrucci L, Resnick SM. Sex differences in cognitive trajectories in clinically normal older adults. Psychol Aging 2016 Mar;31(2):166-175 [FREE Full text] [CrossRef] [Medline]
    38. Grissom NM, Reyes TM. Let's call the whole thing off: evaluating gender and sex differences in executive function. Neuropsychopharmacology 2019 Jan;44(1):86-96 [FREE Full text] [CrossRef] [Medline]
    39. Rosenblum S, Meyer S, Gemerman N, Mentzer L, Richardson A, Israeli-Korn S, et al. The Montreal Cognitive Assessment: is it suitable for identifying mild cognitive impairment in Parkinson's Disease? Mov Disord Clin Pract 2020 Aug;7(6):648-655. [CrossRef] [Medline]
    40. Schultz SK, Hoth A, Buckwalter K. Anxiety and impaired social function in the elderly. Ann Clin Psychiatry 2004;16(1):47-51. [CrossRef] [Medline]
    41. Bekker MHJ, van Mens-Verhulst J. Anxiety disorders: sex differences in prevalence, degree, and background, but gender-neutral treatment. Gend Med 2007;4 Suppl B:S178-S193. [CrossRef] [Medline]
    42. Xu Y, Schneier F, Heimberg RG, Princisvalle K, Liebowitz MR, Wang S, et al. Gender differences in social anxiety disorder: results from the national epidemiologic sample on alcohol and related conditions. J Anxiety Disord 2012 Jan;26(1):12-19. [CrossRef] [Medline]
    43. Alexandre TDS, Corona LP, Nunes DP, Santos JLF, Duarte YADO, Lebrão ML. Gender differences in incidence and determinants of disability in activities of daily living among elderly individuals: SABE study. Arch Gerontol Geriatr 2012;55(2):431-437. [CrossRef] [Medline]
    44. Boehlen FH, Herzog W, Schellberg D, Maatouk I, Schoettker B, Brenner H, et al. Gender-specific predictors of generalized anxiety disorder symptoms in older adults: Results of a large population-based study. J Affect Disord 2020 Feb 01;262:174-181. [CrossRef] [Medline]
    45. Bierman EJM, Comijs HC, Jonker C, Beekman ATF. Effects of anxiety versus depression on cognition in later life. Am J Geriatr Psychiatry 2005 Aug;13(8):686-693. [CrossRef] [Medline]
    46. Booth JE, Schinka JA, Brown LM, Mortimer JA, Borenstein AR. Five-factor personality dimensions, mood states, and cognitive performance in older adults. J Clin Exp Neuropsychol 2006 Jul;28(5):676-683. [CrossRef] [Medline]
    47. Stillman AN, Rowe KC, Arndt S, Moser DJ. Anxious symptoms and cognitive function in non-demented older adults: an inverse relationship. Int J Geriatr Psychiatry 2012 Aug;27(8):792-798 [FREE Full text] [CrossRef] [Medline]
    48. Chippendale T, Boltz M. Living legends: effectiveness of a program to enhance sense of purpose and meaning in life among community-dwelling older adults. Am J Occup Ther 2015;69(4):6904270010p1-690427001011. [CrossRef] [Medline]
    49. Menec VH. The relation between everyday activities and successful aging: a 6-year longitudinal study. J Gerontol B Psychol Sci Soc Sci 2003 Mar;58(2):S74-S82. [CrossRef] [Medline]
    50. Kim J, Lee S, Chun S, Han A, Heo J. The effects of leisure-time physical activity for optimism, life satisfaction, psychological well-being, and positive affect among older adults with loneliness. Ann Leis Res 2016 Oct 03;20(4):406-415. [CrossRef]
    51. Ryu J, Heo J. Relationships between leisure activity types and well-being in older adults. Leis Stud 2017 Sep 22;37(3):331-342. [CrossRef]
    52. Lampinen P, Heikkinen R, Kauppinen M, Heikkinen E. Activity as a predictor of mental well-being among older adults. Aging Ment Health 2006 Sep;10(5):454-466. [CrossRef] [Medline]
    53. Parra-Rizo MA, Sanchis-Soler G. Satisfaction with life, subjective well-being and functional skills in active older adults based on their level of physical activity practice. Int J Environ Res Public Health 2020 Feb 18;17(4) [FREE Full text] [CrossRef] [Medline]
    54. Smith NR, Kielhofner G, Watts JH. The relationships between volition, activity pattern, and life satisfaction in the elderly. Am J Occup Ther 1986 Apr;40(4):278-283. [CrossRef] [Medline]
    55. Keller H. Psychological autonomy and hierarchical relatedness as organizers of developmental pathways. Philos Trans R Soc Lond B Biol Sci 2016 Jan 19;371(1686):20150070 [FREE Full text] [CrossRef] [Medline]
    56. Seligman MEP. Helplessness: On Depression, Development, and Death. New York, NY: WH Freeman; 1992.
    57. Langer N. Resiliency and spirituality: foundations of strengths perspective counseling with the elderly. Educ Gerontol 2004 Aug;30(7):611-617. [CrossRef]

    ‎
    DailyFA: Daily Functional Actualization
    DLQ: Daily Living Questionnaire
    ICF: International Classification of Functioning, Disability, and Health
    STPI: State-Trait Personality Inventory
    WHO: World Health Organization

    Edited by J Wang; submitted 19.11.20; peer-reviewed by JW Tan, C Entwistle; comments to author 28.02.21; revised version received 17.03.21; accepted 22.04.21; published 03.06.21

    Copyright

    ©Sara Rosenblum, Ortal Cohen Elimelech. Originally published in JMIR Aging (https://aging.jmir.org), 03.06.2021.

    This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Aging, is properly cited. The complete bibliographic information, a link to the original publication on https://aging.jmir.org, as well as this copyright and license information must be included.