Resilience in Very Advanced Ages: A Study With Centenarians

Abstract

This study intends to assess the relationship between resilience in extremely long-lived individuals and sociodemographic, cognitive and health status variables, and significant life events. A selected sample of 48 centenarians (mean age = 100.8 years, SD = 1.2; 83.3% female) from two centenarian studies was considered. A resilience score covering five items (aging and usefulness, hopefulness, worryness, loneliness, and control) was considered. Multivariable linear regression analyses were conducted in order to identify predictors of resilience. No significant differences in the resilience score regarding sociodemographic variables or typology of significant life events were found. Our findings underscore that health perception (better) and pain (less frequent) were associated with higher levels of resilience. In being present in extremely long-lived individuals, resilience should be object of interest in further research.

Keywords

centenarians longevity resilience health life events

There are approximately 450,000 centenarians in the world (Koch et al., 2007; Vaupel, 2010). In Portugal, the number of centenarians has doubled in the past 20 years, from 414 in 1996 to 870 in 2006 (Human Mortality Database, 2016), and to 1526 in 2011 (INE, 2016). Centenarians are a group of highly selected “survivors” with unique characteristics that give them an exceptional longevity. Therefore, they could be considered a resilient group as far as they have survived to different adversities and losses throughout their lives, and have overcome in more than two decades the average life expectancy (Koch et al., 2007; Willcox et al., 2008).

Resilience is the capacity to support, recover, and even succeed from adversities that put at risk the development, health, and well-being of a person (Fletcher & Sarkar, 2013; Reppold et al., 2011). This concept has been studied mostly in young persons, but currently, a growing field of research has focused on older adults and on the role of resilience in successful aging (MacLeod et al., 2016). It is a central construct in order to understand the process of getting older and to promote a well succeeded aging in that it enables to understand the adaptation to the difficulties associated with the aging process (Wells, 2009), namely the development of pathologies, and the loss of relatives and friends (de Paula Couto et al., 2011).

Despite the adversities associated with the functional, cognitive, and relational decline related to aging, and the rising risk of psychosocial imbalance (Jopp & Rott, 2006), it is possible to maintain subjective well-being and a positive quality of life in advanced ages (e.g., Araújo et al., 2016; Jopp & Rott, 2006; MacLeod et al., 2016). Centenarians, in overall, manifest a good health perception (Jopp et al., 2016; Kumon et al., 2009), low distress levels, and high levels of satisfaction with life (Jopp et al., 2016; Levitan et al., 2012). Moreover, they were found to present higher resilience levels than younger age groups (e.g., Jopp & Rott, 2006; Kinsel, 2005; Nygren et al., 2005; Yang & Wen, 2015).

Resilience allows oneself to “soften” the impact of negative events in later life (Hildon et al., 2008; Lim et al., 2015), particularly the ones related to the typical health-related losses that characterize more advanced ages. Notwithstanding, the relationship between health and resilience is not congruent (e.g., Fontes et al., 2015; Hardy et al., 2004; Lamond et al., 2008). Some authors only find weak correlations (e.g., Wells, 2009) or do not find any correlation at all (e.g., Schure et al., 2013) between resilience and physical health. Other authors, on the other hand, state that a positive perception of health is correlated with higher resilience levels (Gooding et al., 2012; Hardy et al., 2004; Hildon et al., 2008).

Previous research has also aimed to identify relations between resilience and sociodemographic variables but found no association between resilience and gender, education, marital status, or income (e.g., Fortes et al., 2009; Schure et al., 2013; Wells, 2009). Additionally, since adversity is the antecedent of resilience, some authors have sought to identify the main events that generate stress in old age, as well as to evaluate the relationship between different events and resilience (e.g., de Paula Couto et al., 2011; Hildon et al., 2008). In overall, findings revealed that resilience promotes the acceptance through the reinterpretation of past events based on current events (Hildon et al., 2008); it was also found to moderate the impact of negative life events on depressive symptomatology (Lim et al., 2015).

Zeng and Shen (2010) state that resilience, with an indirect influence on health, is one of the most significant factors to achieve exceptional longevity. In that sense, the study of resilience in centenarians is important because it facilitates the identification of key factors that may potentiate or enhance the adaptation to the challenges of longevity. This study aims to investigate resilience in a sample of Portuguese centenarians and explore its association with sociodemographic characteristics and cognitive and health status variables. The study also intends to explore its association with self-reported important past life events.

Methods

The sample comprised centenarians from the Oporto Centenarian Study (PT100) and the Beira Interior Centenarian Study (PT100 BI). The ﬁrst is a population-based study conducted in the Oporto city and its surrounding geographical area (Oporto Metropolitan Area, which comprises a region of approximately 60 km around Oporto); the second refers to a convenience sample of centenarians living in the interior part of the country with a similar geographical extension around the city of Covilhã (Beira Interior region). The ﬁrst step in the recruitment of centenarians was to identify and locate all potential participants in each municipality and parish, based upon the last National census information and through contacting parish councils, local churches, nursing homes, institutions, and health care centers. Then, in the case of centenarians living in nursing homes, a contact was initially made with the institution’s technical director to introduce the study and request collaboration with the research, followed by contacting the centenarians and/or their proxy. As for the centenarians who lived in the community, researchers contacted the centenarians and/or their relatives directly (in some cases the contact was mediated by local research partners who were enrolled in the identiﬁcation of centenarians: doctors, nurses, social workers, or professionals from the parish council). The recruitment of centenarians was conducted between December 2012 and May 2014, with all inhabitants who were aged 100 years and more at that time being considered eligible.

In the PT100 Oporto Centenarian Study, 186 potential participants were identiﬁed, and of these 140 were effectively face-to-face interviewed; the other 46 centenarians were excluded because they died in the interim or their relatives refused participation because of severe health problems or lack of interest. In the PT100 Beira Interior Centenarian Study, 130 potential centenarians were identiﬁed, and 29 excluded. Eight centenarians died between the ﬁrst contact and the interview, four centenarians refused collaboration due to serious health problems, and ﬁve centenarians didn’t show interest in participating in the study. In four cases, the centenarians or their relatives refused to participate in the study. In eight cases, the reported age could not be validated (Brandão et al., 2019). Information on these projects and on the methodology used for participant selection and data collection can be found elsewhere (Afonso et al., 2018; Ribeiro, Araújo, Teixeira et al., 2015).

Considering the particular interest of this study on resilience, we considered only those centenarians with complete responses to the five items of the resilience score considered (see “Measures” section). Therefore, a final sample of 48 centenarians integrated this particular study, 18 centenarians from the PT100 Oporto Centenarian Study, and 30 centenarians from the PT100 Beira Interior Centenarian Study.

Measures

The data gathering considered the assessment protocol originally designed for the PT100 Oporto Centenarians Study (Ribeiro, Araújo, Duarte et al., 2015). For this particular study, we analyzed the information concerning sociodemographic variables, cognitive and health status, reported life events, along with the variables used to compose the resilience score. All these dimensions are next described:

Sociodemographic characteristics regarding age, gender, marital status, number of living children, living arrangement (community; institution), education (0 years of education; ≥1 year of education), principal source of income (pension; Social Security), and income (per month) were collected.

Cognitive status was assessed by means of a short version of the Mini Mental State Examination (MMSE; Folstein et al., 1975) with a maximum score of 21 points instead of 30, with higher scores indicating a better cognitive status. More specifically, the Language section (reading, writing, and nomination) was not administered because many centenarians suffered from sensory–motor constraints that would have biased the results (Kliegel et al., 2004). So, this short version contains the scales orientation, registration, attention and calculation, and recall, that are less likely to be biased by the poor sensory functioning highly prevalent in the centenarian population (Holtsberg et al., 1995). This shorter version has been used in previous studies with this population (e.g., Jopp & Rott, 2006; Jopp et al., 2016), and some of them have considered a score of 4 or higher to indicate the necessary cognitive capacity for answering self-report questions (e.g., Araújo et al., 2016; Rott et al., 2006). We had also followed this methodology, and we only consider centenarians that fulfilled this criterion in our study. Along with the MMSE, the Global Deterioration Scale (GDS; Mendonça & Guerreiro, 2007; Reisberg et al., 1982) was also used allowing marking old adults in a scale of seven stages of dementia progression, with higher levels corresponding to worse overall status.

Health status was assessed using measures of (a) physical health, considering the ability to perform activities of daily living (BADL and IADL) and measured with items retrieved from the Older Americans Resources and Services (OARS) Multidimensional Functional Assessment Questionnaire (Fillenbaum & Smyer, 1981), with higher scores corresponding to higher levels of functional capacity; (b) self-perceived health, assessed with the question “In general, how would you rate your overall health?” in a five points scale: excellent, very good, good, fair, and poor; (c) reported pain, assessed with the question “how frequently do you feel pain?”, rated in a five point scale: never, seldom, sometimes, often and always; and (d) the previous existence of serious illnesses or injuries during life (yes/no question).

Life events were qualitatively explored by an open question on the more important life events freely recalled by the centenarians: “When do you think about your life, is there any situation or life event particularly important for you, anything that has influenced you much, or anything that was a turning point in your life?”. The interviewer gave the indication that the centenarian could refer up to three important life events.

Resilience was based on a score sum of five items, following the framework used in the “Chinese Longitudinal Health Longevity Survey” (Yang & Wen, 2015). In our study, we have selected five items from the PT-100 protocol (Ribeiro, Araújo, Duarte et al., 2015) that were conceptually equivalent to the ones used by Yang and Wen (2015). The five items are as follows: (a) “Do you feel that as we get older, we become less useful than before?”, that is an item of the “Philadelphia Geriatric Center Morale Scale” (Lawton, 1975); (b) “Do you feel hopeful at this moment?”, from the “Valuation of Life Scale” (Lawton et al., 2001); (c) “I am always worried”, from the “Geriatric Anxiety Inventory” (Pachana et al., 2007); (d) “Do you feel alone?”, from the “UCLA Loneliness Scale” (Russell et al., 1978), and (e) “Do you feel free to decide how to live your own life?”, an item of the “Life Control Assessment Scale”, from the Portuguese PT-100 protocol, “Life Control Assessment Scale” (Ribeiro, Araújo, Teixeira et al., 2015). The items 1 and 3 have been inverted in order to associate higher values to the highest scores of resilience. Given the fact that the five items have different answering scales, we have created z-scores for each item. The final score of resilience corresponds to the sum of the five z-scores, being that the highest sum of z-scores corresponds to the highest score of resilience (DiStefano et al., 2009).

Procedures

Information was collected during one or two sequential semistructured face-to-face interview sessions conducted by two trained researchers at each centenarian’s residence. All variables considered in this study were self-reported, except for the sociodemographic characteristics and the physical health variable (i.e., ADL and IADL functionality) which were provided by the centenarians and/or the proxies. Previous studies had also obtained information on the centenarians’ physical conditions by the proxies and verified high levels of agreement between participants and proxies’ answers (MacDonald et al., 2009). Likewise, as referred previously, we only assessed information on the centenarians’ own perception if he/she was not affected by severe cognitive impairment and was willing to present information on these aspects. All procedures of age validation (i.e., via conﬁrmation with identity card or birth certiﬁcate) and informed consent for participating in the study were fully considered. The study followed all ethical procedures in accordance with the Declaration of Helsinki. The centenarians and their proxy’s interviews were approved by the “Comissão Nacional de Proteção de Dados,” the “Portuguese Data Protection Authority,” under the license n.° 3678/2012, and by the “Comissão de Ética do Hospital Sousa Martins.”

Data Analysis

The sample’s sociodemographic and health status characteristics are presented in accordance with the mean and the standard deviation (SD), or absolute and relative frequencies. The reliability of the score of resilience was calculated through the Cronbach’s α. The associations between resilience and sociodemographic, cognitive and health status variables, and life events were assessed by Student’s t-test, analysis of variance (ANOVA), and the Spearman’s rank correlation coefficient or the Pearson’s correlation coefficient. A multivariable linear regression model was made in order to identify the significant independent predictors resulting from the bivariate analysis. A level of significance of p value .05 was adopted. All the analyses were carried out with the IBM SPSS Statistics Software Version 23 (IBM Corp. Released, 2015).

In order to gain a deeper understanding on the important life events reported by centenarians, qualitative data from the semistructured interviews regarding this question were audiotaped and transcribed for analysis; this was conducted with the support of the NVIVO 9 software (QSR International Pty Ltd, 2010). Initially, the transcripts were read transversally by two of the researchers, searching for an overall view of the life events reported, and then, in the framework of the affective valences associated with them, life events were coded in one of the three categories: positive, negative, or neutral event. The first category was considered when past events were positive, sometimes with a feeling of mastery and self-efficacy, and were described as pleasant or joyful. The second was considered when past events were described in a negative way, being interpreted as demanding and difficult, or to which were allocated unpleasant emotions such as loss, unhappiness, cholera (i.e., wrath), or sacrifice. Finally, neutral events were considered as so when they had no pleasant or unpleasant emotions associated, were described with indifference, and/or were vaguely exposed.

Results

Sociodemographic Characteristics

The sample was constituted by 48 centenarians. Most centenarians were female (83.3%), with an average age of 100.8 years (SD = 1.2 years; minimum = 100 years and maximum = 105 years), widowed (85.4%), and had at least one living children (83.3%). More than half had only one or more years of schooling (58.3%), lived in the community (60.4%), and had an income between €250 and €500 per month (60.0%).

Health Status

Table 1 presents the centenarians’ physical and cognitive status. Mean BADL ratings were 10.1 (SD = 3.6; minimum = 1 and maximum = 14), and mean IADL ratings were 4.9 (SD = 3.4; minimum = 0 and maximum = 14), with lower levels indicating more dependency. The majority referred to have faced a serious health problem at some point in their lives (75.0%), and only 22.9% referred not feeling pain. Almost half of the sample evaluated their health as good, very good, or excellent (45.8%). Regarding the cognitive status, mean MMSE brief rating was 12.9 (SD = 5.1; minimum = 4 and maximum = 21) with lower levels indicating more cognitive impairment; GDS ratings indicated that 42.6% of the sample presented no subjective complains of memory deficit, and other 42.6% had very mild cognitive impairment (age-associated memory impairment), with subjective complains of memory deficits.

Table 1

Centenarians’ Physical and Cognitive Status.

	N	n	%
Subjective health	48
Poor		8	16.7
Fair		18	37.5
Good/very good/excellent		22	45.8
Global Deterioration Scale	47
No subjective complaints of memory deficit		20	42.6
Subjective complaints of memory deficit		20	42.6
Earliest clear-cut deficits		3	6.4
Clear-cut deficit on careful clinical interview		4	8.5
Very serious health problem	48
No		12	25.0
Yes		36	75.0
IADL, mean (SD)	47	4.9 (3.4)
BADL, mean (SD)	48	10.1 (3.6)
MMSE Brief, mean (SD)	48	12.9 (5.1)
Frequency of pain	48
Never		11	22.9
Seldom		10	20.8
Sometimes		11	22.9
Often/always		16	33.3

Note. IADL = Instrumental Activities of Daily Living; BADL = Basic Activities of Daily Living; MMSE = Mini Mental State Examination.

Resilience Score

Table 2 presents the distribution of the five items of the resilience score. The analysis of the resilience score revealed a Cronbach’s α of 0.633. In small scales, values of Cronbach’s α of 0.6 are good because when there are few items, the alpha tends to underestimate internal consistency (Terwee et al., 2007).

Table 2

Distribution of Items That Composed the Resilience Score.

	N	n	%
Do you think that as one ages, one gets less useful?	48
No		9	18.8
More or less		8	16.7
Yes		31	64.5
I feel hopeful right now	48
No		18	37.5
More or less		13	27.1
Yes		17	35.4
I worry a lot of the time	48
No		31	64.6
Yes		17	35.4
Do you feel alone?	48
Yes, very often		11	22.9
Sometimes		14	29.2
Rarely		9	18.8
Never		14	29.2
Do you feel free to decide how you want to live your life?	48
No		15	31.3
Yes		33	68.8

The analysis of differences in resilience scores concerning sociodemographic characteristics showed no significant differences regarding education (t (46) =−0.87, p = .27), source of income (t (46) =−1.45, p = .51), or living arrangements (t (46) =0.70, p = .12) (Table 3). The analysis of differences in resilience scores concerning health status characteristics showed no significant differences regarding a history of serious health problem (t (46) =1.2, p = .24), or the cognitive status (r = .215, p = .143). Conversely, there were significant statistical differences between resilience and four other variables: self-perceived health, F (2,45) =7.11, p = .002, BADLs (rs = .359, p = .013), IADLs (rs = .312, p = .031), and pain frequency, F (3,44) =6.52, p = .001.

Table 3

Resilience Score by Sociodemographic Characteristics.

	n	Mean (SD)	t(46)
Education years
0	20	−0.38 (3.43)	−0.87
≥1	28	0.43 (2.99)	−0.87
Income source
Pension	31	.0.39 (3.22)	−1.45
Social security	17	0.98 (2.99)	−1.45
Living arrangements
Institution	19	−0.31(3.67)	0.70
Community	29	0.36 (2.85)	0.70

The variables significantly related to resilience, identified in the bivariate analysis (i.e., self-perceived health, BADL, IADL, and pain frequency) were considered in the multivariable linear regression model as potential predictors of resilience. Coefficient estimates, standard errors (se), and the respective confidence intervals of the model are presented in Table 4. The model accounted for 49.1% of the variance of the score of resilience. In the final model, only self-perceived health and pain severity remained significant predictors of the resilience score. Centenarians that classified their health as fair (b = 3.20, 95% confidence interval [CI] 0.86–5.53) or as good/very good/excellent (b = 2.84, 95% CI 0.36–5.32) presented better resilience scores when compared to the centenarians who classified their health as poor, adjusting for the other variables. In the same way, centenarians who reported lack of pain presented higher resilience scores, when compared to those who reported experiencing pain often or always (b = 3.19, 95% CI 1.05–5.33), controlling for the other variables included in the model.

Table 4

Multivariable Linear Regression Model for Resilience Score.

	B (se)	95% CI	p
Subjective health
Poor vs. fair	3.20 (1.15)	0.86–5.53	.008**
Poor vs. good/very good/excellent	2.84 (1.22)	0.36–5.32	.026*
IADL	0.27 (0.15)	−0.03–0.58	.078
BADL	−0.09 (0.15)	−0.39–0.21	.549
Pain
Often/always vs. never	3.19 (1.06)	1.05–5.33	.004**
Often/always vs. seldom	1.85 (1.15)	−0.46–4.17	.114
Often/always vs. sometimes	−0.55 (0.99)	−2.56–1.46	.586

Note. IADL = Instrumental Activities of Daily Living; BADL = Basic Activities of Daily Living; CI = confidence interval. R² = 0.491; *p < .05. **p < .01.

Significant Life Events

The qualitative analysis of the centenarians’ reported life events and subsequent codification enabled us to find that 66.7% of the centenarians narrated a positive life event, even that more than half identified negative life events (52.1%; Table 5). Concerning the relation between life events and resilience scores, no significant differences between centenarians who reported positive events (M = 0.10, SD = 0.58) versus centenarians who did not report positive events, M = 0.09, SD = 0.75; t (46) =−0.01, p = .995, were found; similarly, no differences were found regarding centenarians who reported negative events (M = −0.56, SD = 0.64) versus centenarians who did not report negative events, M = 0.81, SD = 0.63; t (46) =1.51, p = .138).

Table 5

Distribution of the Classification of Life Events (N = 48).

Life event	n ^a	%
Positive event	32	66.7
Negative event	25	52.1
Neutral event	1	2.1
No answer	4	8.3

Note. ^aFrequencies were not mutually exclusive.

Discussion

This study focused on a construct of great importance in the area of psychology, but still understudied in very advanced age—resilience. Resilience is present in old age and has been referred to as a factor that significantly contributes to achieve an advanced longevity (Zeng & Shen, 2010). Our study discloses relevant findings, namely the importance of health-related dimensions (self-perceived health and pain frequency) for resilience.

Previous to the discussion of the predictors of resilience, a note to the profile of our centenarians’ sample should be made. The sociodemographic characteristics of our sample corroborate the profile of the centenarians presented in other international studies (e.g., Hagberg & Samuelsson, 2008; Kumon et al., 2009) in what regards the preponderance of females and widows; even so, previous centenarians’ studies, for instance, those conducted in Georgia and New England, pointed to a higher number of centenarians living in institutions (e.g., Kumon et al., 2009), while in our study most of them still lived in the community, which is in line with what happens for the resident population aged 100+ in Portugal and in most European countries (Teixeira et al., 2017).

The analysis between resilience and sociodemographic variables did not reveal any significant statistical differences. With respect to education, despite the highest resilience levels found in centenarians with at least 1 year of schooling, no significant differences between centenarians who had attended formal school and those who were illiterate were found. Fortes et al. (2009) suggest that significant differences between these two dimensions would be attained with adults who had attended higher education.

Regarding income, the results of the study corroborate the nonassociation between resilience and socioeconomic status found in previous studies (e.g., Fortes et al., 2009; Wells, 2009). Likewise, no association was found between resilience and living arrangements, even that higher levels of resilience were found in centenarians living in the community. As institutionalization is commonly associated with high functional dependence and a reduction of the social support network (e.g., Araújo, 2010; Ribeiro & Araújo, 2017), this can contribute to lower levels of resilience.

Our findings regarding the relation between resilience and health status variables should also be object of reflection. On one hand, the fact that physical health (i.e., functional level) was not found to be associated with resilience corroborates the results of other studies, as the one carried out by Schure et al. (2013). On the other hand, our study contradicts the study of Wells (2009), who has found a positive association between resilience and physical health. Notwithstanding, this author also states that the weak relationship between them indicates that physical health decay itself does not reduce the resilience levels (Wells, 2009).

Concerning the cognitive function, our study found no significant statistical relationship with resilience, which corroborates the results of Fontes et al. (2015). However, literature is inconsistent, and other studies have found an association between these two variables, stating that a higher level of resilience is related to a better cognitive function (Fortes et al., 2009; Lamond et al., 2008). Consequently, further research is needed in order to clarify the relationship between these two variables in very advanced ages. Moreover, we should take into consideration that these inconsistent results could be (partially) explained by the limitations of using cognitive measurement tools in very old adults, particularly centenarians. The application of some cognitive screening tools in these studies seems to impair the results of the older ones, due to their low education and their sensory limitations (Holtsberg et al., 1995). Therefore, it is important to stress that the data collected in the present study come from a subgroup of selected centenarians, who were able to reply to the resilience assessment score, which is an indicator of their better cognitive functions.

Finally, in what concerns the association between resilience and significant live events, once again no significant association was found. Some previous research indicated a positive association between resilience and negative life events (e.g., Hildon et al., 2010), but these studies tend to objectively measure adverse events (e.g., de Paula Couto et al., 2011; Lim et al., 2015), in contrast to what happens in our study. In the present study, the open question used has allowed the centenarians to report any remarkable event living by themselves, which does not directly imply the remembrance of any adverse experience in particular, but has intended to make an appeal to recall their life story narratives, which posit some cognitive and emotional processes that influence their memories, perceptions, and emotions (Gonçalves & Henriques, 2005). The narrative of resilient individuals tends to stress the effective management of adversities, emphasizing the feeling of mastering these situations (Randall et al., 2015). Therefore, the results of the study could be a reflection of the fact that the centenarians with higher resilience levels had built their narratives based on their own overcomes of adversities. Indeed, we found that centenarians who had not identified negative situations as the most important life events presented higher scores of resilience, and this may be related to their focus on the positive adaptation to life challenges.

The present study also had the intention of identifying the independent predictors of resilience. Initially, the results showed that functional capacity, self-perceived health, and pain frequency were potential predictors of resilience. However, in the multivariable regression model, only self-perceived health and pain frequency maintained their significance as predictors of resilience. It is known that the experience of pain is not only influenced by physical injuries but also by physical, psychological, and social factors (Ramírez-Maestre et al., 2004; Willman et al., 2013). With regard to the relationship between pain and aging, there are some studies stating that the frequency of pain tends to get lower in individuals aged 70 years and over, whereas other studies stress the prevalence of pain in people as they get older (e.g., Willman et al., 2013). However, it has been also pointed out, in other studies, the positive value of resilience in the adaptation processes of older people to chronic pain (Ríos-Velasco, 2011) stressing that individuals with higher resilience scores have lower pain levels (Schure et al., 2013). Similarly, the present study corroborates these results, adding that the adaptation to pain in centenarians is an explanatory factor of resilience. Likewise, it was found a significant relationship between resilience and self-perceived health, in line with the results of other studies carried out with other age subgroups (e.g., Gooding et al., 2012; Ruiz Párraga & López Martínez, 2012). These results stress the importance of the psychosocial and contextual variables in the health self-perception, given that centenarians, in spite of having several morbidities, present a good one. On this matter, Domajnko and Pahor (2015) had recently concluded that resilient older adults tend to have a better health perception, even if they are in a pathological condition.

It is important to consider that, without assuming causal chains, multivariate regression analysis will not be able to determine the direction of correlations between variables (Pestana & Gageiro, 2008). Thus, the results of this study suggest a complex relationship between the included variables: resilience, pain frequency, and self-perceived health. Accordingly, it is possible to find multidirectional relationships between them. In that sense, two explanatory hypotheses may be advanced: (a) centenarians with lower levels of pain frequency and a better health perception would be more resilient; and (b) their higher resilience levels could explain their lower frequency of pain and their better health perception. This last hypothesis has been chosen to explain the observed relationship. Resilience is the individuals’ ability to adapt to adverse circumstances with a good performance (Ong et al., 2009; Zeng & Shen, 2010). Given the frequent existence of chronic and acute health problems, advanced age is often characterized by physical, social, and relational limitations (Hildon et al., 2010). Consequently, individuals may adopt resilient behaviors in order to optimize and compensate their health problems and limitative condition (Baltes & Baltes, 1991; Gooding et al., 2012; Ruiz Párraga & López Martínez, 2012). In that sense, with a more resilient attitude, accordingly to the results of our study, it may be possible to achieve a better adaptation to one’s health constraints, giving them a better health perception and pain management.

Despite the importance of our study findings, it is mandatory to pay attention to its limitations. First, considering that the sample is constituted by a selected number of centenarians who answered to the resilience score, this can indicate a better level of functioning, and also can be an indicator of higher resilience. Second, it is also a limitation the consistency of the measures adopted to assess resilience, so the findings should be interpreted with caution. While this may true, given the fact that this study has not included a tool to measure resilience in the initial assessment protocol, it was considered that the scores of resilience used in previous studies including centenarians (e.g., Yang & Wen, 2015; Zeng & Shen, 2010), would be an appropriated measure.

The overall results point out several challenges in research and clinical practice. Above all, it would be important, in future studies, to clarify the relationship between health perception and pain frequency. Given that advanced longevity is a heterogeneous stage of the lifespan, it would be also important to continue the study of resilience because this one facilitates: the management of adversities, the maintenance of the emotional equilibrium, and the best functional levels of the centenarians. Further research should be conducted considering a larger sample of centenarians (with more diverse cognitive and physical health status) and analyze the congruence between the score of resilience used in our study and other assessment measures of resilience. Considering the dynamical relationship between resilience and variables related to the health status, the development of interventions in order to increase the scores of resilience as a key construct in the management and adaption to the challenges of longevity would have a positive influence on the centenarians’ well-being.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conﬂicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The PT100 Oporto Centenarian Study was supported by the Fundação para a Ciência e Tecnologia (FCT; Grant Pest-C/SAU/UI0688/2011 and C/SAU/UI0688/2014).

ORCID iD

Daniela Brandão

Author Biographies

Ana Saraiva Amaral is a psychologist, PhD student at University of Coimbra, Coimbra, Portugal; researcher (CINEICC and CICS-UBI).

Rosa Marina Afonso is a psychologist, auxiliary professor at the Department of Education and Psychology – University of Beira Interior, Covilhã, Portugal; researcher (CINTESIS-ICBAS).

Daniela Brandão, is a gerontologist, with a PhD in Clinical and Health Services Research; researcher (CINTESIS-ICBAS).

Laetitia Teixeira is a biostatistitian, invited assistant professor at the Institute of Biomedical Sciences Abel Salazar, University of Porto, Porto, Portugal; researcher (CINTESIS-ICBAS).

Oscar Ribeiro is a psychologist, auxiliary professor at the Department of Education and Psychology – University of Aveiro, Aveiro, Portugal; researcher (CINTESIS-UA) and PI of the PT100 Project.

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