The impact of ADL disability in middle-aged and older adults on the incidence of hip fractures and the mediating role of depression: a longitudinal evidence from CHARLS.

Background: Hip fractures pose a major public health burden in aging populations, driven by rising osteoporosis prevalence and demographic aging. In China, nearly 2 million new cases occurred in 2019, disproportionately affecting middle-aged and older women. Despite extensive research on biomedical risk factors, mechanistic links between Activities of Daily Living (ADL) disability and hip fractures remain unclear.

Objectives: This study aims to elucidate the relationship between ADL disability and hip fractures incidence among middle-aged and older adult individuals in China. Furthermore, it seeks to explore the potential mediating role of depressive symptoms in this association, thereby contributing to a deeper understanding of hip fracture risk determinants.

Methods: This longitudinal analysis utilized data from the China Health and Retirement Longitudinal Study (CHARLS) covering the period from 2011 to 2015. The study involved 5,066 participants who had no pre-existing hip fractures at baseline. ADL functional capacity was assessed by categorizing Instrumental Activities of Daily Living (IADL) and Basic Activities of Daily Living (BADL). Depressive symptoms were measured using the Center for Epidemiological Studies Depression Scale (CES-D-10). The incidence of hip fractures was documented over a four-year follow-up period, and both logistic regression and mediation analyses were performed to investigate the associations.

Results: Within the follow-up cohort, a total of 256 incident hip fractures were recorded. After adjusting for confounding variables, IADL disability emerged as a significant predictor of fracture risk (OR = 1.42, 95% CI: 1.07-1.89,  = 0.017), while BADL disability was found to have an even greater impact (OR = 1.96, 95% CI: 1.47-2.61,  < 0.001). Mediation analysis indicated that depressive symptoms accounted for a substantial portion of the association, mediating 43.8% of the relationship between IADL disability and hip fractures risk, and contributing to 23.4% of the association between BADL disability and hip fractures.

Conclusion: ADL disability, particularly BADL, independently predicts hip fractures in older Chinese adults. Depressive symptoms mediate 43.8% of the risk associated with IADL and 23.4% of the effect related to BADL. Therefore, integrating depression management into ADL-focused interventions may enhance strategies for fracture prevention.