The Association between Sleep Quality and Activities of Daily Living: Empirical Analysis of Rural Elderly in Central and Western China

Background and purpose: Activities of Daily Living (ADL) are fundamental for healthy aging and the maintenance of independence. With the aging population expanding, especially in rural areas, maintaining autonomy among older adults has become a pressing public health concern. Although prior research has linked poor sleep quality to diminished ADL performance, the mechanisms underlying this association remain unclear. Guided by self-depletion theory, which posits that reduced physical resources can lead to sustained cognitive, emotional, and social behavioral impairments, this study examined whether poor sleep quality indirectly influences ADL through these depletion pathways.

Methods: A multi-stage random sampling approach was used to recruit adults aged 60 and above from two provinces and twelve townships in central and western China. Trained interviewers conducted face-to-face interviews using standardized, validated instruments. ADL was assessed using scales encompassing both Basic Activities of Daily Living (BADL) and Instrumental Activities of Daily Living (IADL), with higher scores indicating greater functional limitations. Sleep quality was measured by the Pittsburgh Sleep Quality Index (PSQI). Cognitive, emotional, and social behavioral depletion were assessed using the Mini Mental State Examination (MMSE), the 10-item Center for Epidemiologic Studies Depression Scale (CESD-10), and a social participation scale measuring 11 types of interpersonal and community engagement. Correlational analyses examined relationships among key variables. Structural equation modeling (SEM) was used to evaluate a multiple mediation model testing whether cognitive decline, depressive symptoms, and reduced social participation mediated the relationship between sleep quality and ADL performance.

Results: The sample consisted of 52.7% male participants, with the majority aged 70–79 (47.7%) and married (74.6%). Significant associations were found between sleep quality, ADL, and all three dimensions of self-depletion. Mediation analysis showed that cognitive, emotional, and social pathways fully mediated the relationship between sleep quality and ADL. Cognitive function emerged as the primary mediator (indirect effect = .070, p < .001), accounting for 48.28% of the total effect. Depressive symptoms were the secondary mediator (indirect effect = .067, p < .001; 46.21% of the total effect). Social participation played a supplementary role (indirect effect = .008, p = .038), contributing 5.52% of the total effect.

Conclusions and Implications: Poor sleep quality not only directly impairs ADL in rural older adults but also indirectly affects their daily functioning through cognitive, emotional, and social pathways. Interventions aiming to improve sleep quality could alleviate these forms of self-depletion and help preserve independence. A multi-level response is essential: older adults should be empowered to take responsibility for their sleep health; families should provide emotional and communicative support; and public health and community systems should enhance sleep education and care resources. These findings underscore the importance of integrated strategies in social work and public health to promote functional aging and quality of life in rural settings.