Correlation between musculoskeletal system function and pre-depressive states in elderly cancer patients: A single-center cross-sectional study

Abstract

BACKGROUND

Studies have shown that locomotive syndrome (LS) is significantly correlated with adverse outcomes, such as decreased self-care abilities, fractures, and increased mortality. Subthreshold depression (StD) is considered an independent predictor of clinical depression, regarded as its prodromal stage, and even linked to increased mortality risk. Limited research has addressed the prevalence and relationship between LS and StD in elderly cancer patients. Understanding the prevalence of LS and StD among elderly cancer patients and elucidating their relationship will provide evidence to support the development of targeted interventions, thereby improving health outcomes in this population.

AIM

To investigate the relationship between musculoskeletal system function and pre-depressive states in elderly cancer patients.

METHODS

A convenience sampling method was employed to recruit 500 elderly cancer patients undergoing follow-up visits at the Department of Oncology, Affiliated Hospital of Jiangnan University, from April 2024 to December 2024. Participants completed the general information questionnaire, the 25-question Geriatric Locomotive Function Scale, and the Geriatric Depression Scale-Short Form-15. Influencing factors were analyzed, and correlation analyses were performed.

RESULTS

A total of 483 elderly cancer patients successfully completed the study. The prevalence of LS and StD among participants was 56.5% and 38.7%, respectively. Logistic regression analysis identified age, tumor metastasis, exercise habits, and the presence of StD as significant risk factors for LS in elderly cancer patients. Additionally, having three or more chronic diseases and LS were significant predictors for developing StD. Spearman’s correlation analysis revealed a significant positive correlation between LS and StD (r = 0.424, P < 0.001).

CONCLUSION

Elderly cancer patients exhibit a high prevalence of LS and StD, conditions which are positively correlated and mutually influential. Thus, it is critical to monitor and address pre-depressive states while evaluating and managing motor function in this population.

Key Words: Elderly cancer patients; Musculoskeletal function; Locomotive syndrome; Pre-depressive state; Correlation

Core Tip: Cancer patients often experience impaired ability to perform daily living activities and diminished social engagement due to tumor progression, treatment-related side effects, or pain, significantly impacting their psychological health. Limited research has addressed the prevalence and relationship between locomotive syndrome and subthreshold depression in elderly cancer patients. Therefore, this study aimed to assess the prevalence of locomotive syndrome and subthreshold depression in elderly cancer patients, investigate their association, and provide evidence to support strategies aimed at preventing or mitigating musculoskeletal dysfunction and depression through targeted interventions.

INTRODUCTION

Locomotive syndrome (LS) is a high-risk condition characterized by difficulty standing, walking, or performing other movements due to weakened or impaired locomotor organs (bones, joints, muscles, nerves, etc.). It typically leads to limb dysfunction, increased dependence on care, and potential confinement to bed rest[1]. Studies have shown that LS is significantly correlated with adverse outcomes, such as decreased self-care abilities, fractures, and increased mortality[2]. In recent years, the incidence of malignant tumors among older adults has steadily increased. The national cancer report released by the National Cancer Center indicated that, in 2020, approximately 19.29 million new cancer cases were reported globally, of which 4.57 million occurred in China. Notably, the majority of new cancer patients were aged between 60 and 79 years[3]. Elderly cancer patients are particularly vulnerable to LS due to prolonged immobilization causing disuse atrophy, secondary osteoporosis, joint contractures, chemotherapy-induced peripheral neuropathy, and lymphedema resulting from radiotherapy or surgical interventions[4,5].

With the aging of China’s population and improvements in living standards, increasing attention is being directed toward the mental health of elderly cancer patients[6,7]. Depression, characterized by persistent low mood, reduced interest, and diminished energy, is among the most common psychological disorders[8]. According to recent statistics from the World Health Organization, approximately 350 million individuals globally suffer from varying degrees of depression, with an estimated adult prevalence of 4.4%[9]. Depression prevalence continues to rise rapidly, ranking as the third most burdensome disease worldwide, and is anticipated to become the leading global health burden by 2030[10]. Subthreshold depression (StD), also termed subsyndromal depression, refers to “a group of symptoms consistent with depression but insufficient in duration or number of symptoms to meet diagnostic criteria for clinical depression”[11]. Although not meeting formal diagnostic criteria, StD is considered an independent predictor of clinical depression, regarded as its prodromal stage, and even linked to increased mortality risk[12]. Elderly cancer patients exhibit distinct clinical vulnerability due to the dual burden of age-related physiological decline and cancer itself[4]. This vulnerability is manifested not only in reduced tolerance to conventional anti-tumor therapies but also in progressive depletion of multisystem functional reserves[5]. Notably, LS and StD-two frequently underrecognized geriatric syndromes-may exacerbate poor prognosis in this population through complex biopsychosocial mechanisms[4,6].

Musculoskeletal function and mental health status are closely interrelated[13]. Cancer patients often experience impaired ability to perform daily living activities and diminished social engagement due to tumor progression, treatment-related side effects, or pain, significantly impacting their psychological health. Additionally, depression is a common affective disorder among cancer patients, which may exacerbate somatic dysfunction and complicate the management of coexisting physical illnesses[14]. Limited research has addressed the prevalence and relationship between LS and StD in elderly cancer patients. Therefore, this study aimed to assess the prevalence of LS and StD in elderly cancer patients, investigate their association, and provide evidence to support strategies aimed at preventing or mitigating motor dysfunction and depression through targeted interventions.

MATERIALS AND METHODS

Participants

A convenience sampling method was employed to recruit 500 elderly cancer patients who attended follow-up visits at the Department of Oncology of Jiangnan University Hospital from April 2024 to December 2024. Participants voluntarily enrolled and provided written informed consent. The study protocol was approved by the Ethics Committee of the Affiliated Hospital of Jiangnan University (Approval No. LS2023101). The study was conducted in accordance with the Declaration of Helsinki.

Inclusion criteria: (1) Age ≥ 60 years; (2) Diagnosis of malignant tumors based on the 8^th edition of the international tumor-node-metastasis staging criteria, clearly confirmed by physicians, without bone metastasis; (3) Ability to independently manage activities of daily living; (4) Stable vital signs and medical condition; (5) No history of musculoskeletal dysfunction resulting from primary orthopedic conditions; and (6) Provision of informed consent and voluntary participation.

Exclusion criteria: (1) Cognitive impairment, confusion, or loss of consciousness impeding questionnaire completion; and (2) Clear diagnosis of any medical condition contraindicating physical activity.

Research instruments

General information questionnaire: This questionnaire was designed by the research team, covering demographic details including gender, age, body mass index, and residence, as well as disease-specific information such as comorbid chronic conditions, cancer treatments received, and any treatment-related sequelae.

Geriatric Locomotive Function Scale: The 25-question Geriatric Locomotive Function Scale (GLFS-25), developed by Seichi, assesses LS among elderly patients, and its validity and applicability for elderly cancer patients have been confirmed by Chinese scholars[15,16]. The scale consists of 25 items across four dimensions: Pain, activities of daily living, social function, and mental health status. Each item utilizes a 5-point Likert scale, ranging from 0 (no difficulty) to 4 (extreme difficulty), with higher scores indicating greater functional impairment. The GLFS-25 outperforms alternative measures in sensitivity for early locomotive dysfunction detection, while its comprehensive 25-item structure provides dual assessment of physical capacity and social participation[15]. The Cronbach’s alpha for the overall scale was 0.927, and for individual dimensions ranged from 0.750 to 0.930. The test-retest reliability for individual items ranged between 0.791 and 0.949. A total score of ≥ 16 indicated the presence of LS.

Geriatric Depression Scale-Short Form: StD among elderly cancer patients was evaluated using the Geriatric Depression Scale-Short Form-15 (GDS-15) scale[17]. This scale comprises 15 items grouped into five dimensions: Unhappiness, apathy and anxiety, loss of hope, memory impairment, and reduced social activity. Ten items are scored as 1 point for “Yes” responses and 0 points for “No” responses, whereas the remaining five items are scored inversely (1 point for “No”, 0 points for “Yes”). The GDS-15 has been widely adopted in geriatric populations. This assessment tool minimizes interference from somatic symptoms in cancer patients and, owing to its concise item structure, demonstrates significantly higher completion rates compared to longer versions[17]. The Cronbach’s alpha coefficient for the GDS-15 was 0.793, with a one-week test-retest reliability of 0.728. Total scores range from 0 to 15, and a score ≥ 6 indicates the presence of StD.

Data collection

Prior to conducting the survey, support was secured from the administrators of the Department of Oncology at Jiangnan University Hospital. Eligible elderly cancer patients who provided informed consent were recruited through direct inquiries and posted announcements. Two oncology clinical nurses, trained uniformly, distributed questionnaires to the participants collectively in a conference room. Before administering the survey, participants were briefed on the study’s objectives and procedures. Participants completed the questionnaires independently, except for those who were unable to do so; in these cases, the researchers filled out the questionnaire according to the participants’ verbal responses. Researchers provided on-site assistance and guidance as needed, taking care to avoid suggestive prompts to maintain data quality, and collected all questionnaires immediately after completion. The implementation process is summarized in Figure 1.

Figure 1 The flow chart of the implementation of this study.

Statistical analysis

Data were entered independently by two individuals using EpiData version 3.1 to establish the database. Statistical analyses were conducted using SPSS 25.0 software. Categorical data were expressed as frequencies and percentages, and comparisons were made using the χ² test. Spearman’s correlation analysis was used to examine the association between GLFS-25 and GDS-15 scores. Binary logistic regression analysis was employed to identify risk factors for LS and StD. Statistical significance was set at P < 0.05.

RESULTS

Prevalence of LS and StD among elderly cancer patients

A total of 500 questionnaires were distributed and collected on-site, with 483 valid responses received, yielding an effective response rate of 96.6%. The participants consisted of 218 males and 265 females, with a median age of 65 years. Of these, 408 Lived with family members. The mean body mass index was 21.7 ± 2.4, indicating normal weight status. A total of 384 participants had chronic diseases, defined in this study as clinically diagnosed and managed hypertension, stroke, heart disease, diabetes mellitus, hyperuricemia, and chronic obstructive pulmonary disease. LS was identified in 273 participants (56.5%), while StD was present in 187 participants (38.7%). The distribution of primary tumor diagnoses among participants is illustrated in Figure 2. The prevalence of LS and StD across elderly cancer patients with various characteristics is summarized in Table 1.

Figure 2 Diagnostic distribution of primary malignancies in elderly cancer patients.

Table 1 Comparison of the incidence of locomotive syndrome and subthreshold depression in elderly cancer patients with different characteristics.

Variables	Classification	Total	LS			StD
			Number	χ2	P value	Number	χ2	P value
Gender	Male	218	102	5.546	0.062	86	6.455	0.053
	Female	265	171			101
Age	60-69	308	136	7.675	0.009	71	3.233	0.234
	70-79	128	95			75
	80-90	47	42			41
Residence	Live alone	75	13	2.011	0.321	11	1.232	0.348
	With co-residents	408	260			176
Comorbid chronic diseases	0	99	16	19.874	0.027	15	12.324	0.033
	1	188	86			58
	2	132	110			66
	≥ 3	64	61			48
BMI	Underweight	43	33	9.568	0.054	18	11.932	0.051
	Normal	304	145			122
	Overweight	106	72			33
	Obesity	30	23			14
Regular exercise habits	None	324	215	5.478	0.021	163	2.534	0.038
	Yes	159	58			24
Type of former occupation	Physical work	163	68	4.684	0.042	72	5.457	0.076
	Non-physical work	320	205			115
Cancer metastasis	None	306	104	7.857	0.002	87	6.232	0.031
	Yes	177	169			100
Operation history	None	279	123	9.876	0.061	76	7.624	0.122
	Yes	204	150			111
Radiotherapy history	None	302	172	7.643	0.058	89	9.384	0.122
	Yes	181	180			98
Chemotherapy history	None	67	12	8.582	0.072	7	7.893	0.122
	Yes	416	261			180
StD	None	296	121	23.324	< 0.001
	Yes	187	152
LS	None	210				35	21.132	< 0.001
	Yes	273				152

BMI: Body mass index; LS: Locomotive syndrome; StD: Subthreshold depression.

Multifactorial analysis of LS and StD among elderly cancer patients

Multifactorial analysis of factors associated with LS: Binary logistic regression analysis was conducted, taking LS as the dependent variable and including factors statistically significant in univariate analysis as independent variables. Results indicated that age, presence of cancer metastasis, lack of regular exercise habits, and presence of StD were significant risk factors for LS among elderly cancer patients (P < 0.05). Variable assignment criteria are provided in Table 2, and detailed regression analysis results are presented in Table 3.

Table 2 Independent variable assignment.

Independent variable	Assignment method
Age	60-69 = 0; 70-79 = 1; 80-90 = 2
Regular exercise habits	None = 0; yes = 1
Type of former occupation	Non-physical work = 0; physical work = 1
Cancer metastasis	None = 0; yes = 1
Comorbid chronic diseases	0 = 0; 1 = 1; 2 = 2; ≥ 3 = 3
StD	None = 0; yes = 1

StD: Subthreshold depression.

Table 3 Logistic regression analysis of locomotive syndrome in elderly cancer patients.

Variables	β	SE	χ2	P value	OR	95%CI
Constant	-3.245	0.477	48.347	< 0.001	N/A	N/A
Age (60-69 as reference)
70-79	0.559	0.281	3.969	0.046	1.749	1.009-3.032
80-90	1.311	0.610	4.614	0.022	3.709	1.122-12.266
Cancer metastasis (none as reference)
Yes	0.403	0.384	1.102	0.026	0.668	0.314-1.421
Regular exercise habits (none as reference)
Yes	-0.403	0.384	1.102	0.038	0.668	0.314-1.421
StD (none as reference)
Yes	1.209	0.272	19.728	< 0.001	3.228	1.966-5.714

StD: Subthreshold depression; OR: Odd ratio; CI: Confidence internal; N/A: Not applicable.

Multifactorial analysis of factors associated with StD: Binary Logistic regression analysis was performed, using StD as the dependent variable and factors significant in univariate analysis as independent variables. Results demonstrated that having three or more chronic diseases and the presence of LS were significant predictors of StD in elderly cancer patients (P < 0.05). Variable assignment criteria are detailed in Table 4, and specific regression results are shown in Table 5.

Table 4 Independent variable assignment.

Independent variable	Assignment method
Regular exercise habits	None = 0; yes = 1
Cancer metastasis	None = 0; yes = 1
Comorbid chronic diseases	0 = 0; 1 = 1; 2 = 2; ≥ 3 = 3
LS	None = 0; yes = 1

LS: Locomotive syndrome.

Table 5 Logistic regression analysis of factors influencing subthreshold depression in elderly cancer patients.

Variables	β	SE	χ2	P value	OR	95%CI
Constant	-2.187	0.545	39.113	< 0.001	N/A	N/A
Comorbid chronic diseases (0 as reference)
1	0.628	0.424	2.193	0.139	1.874	0.816-4.301
2	0.486	0.448	1.179	0.278	1.626	0.676-3.913
≥ 3	1.291	0.395	10.688	0.001	3.521	1.677-7.886
LS (none as reference)
Yes	1.187	0.279	18.123	< 0.001	3.102	1.898-5.662

LS: Locomotive syndrome; OR: Odd ratio; N/A: Not applicable; CI: Confidence internal.

Correlation analysis between LS and StD among elderly cancer patients

Spearman’s correlation analysis revealed that the total GLFS-25 score and its 4 dimensions were significantly positively correlated with StD in elderly cancer patients (P < 0.001). Detailed correlation data are provided in Table 6.

Table 6 Correlation of subthreshold depression and dimensions with 25-question Geriatric Locomotive Function Scale.

Variables	R	P value
GLFS-25	0.424	< 0.001
Pain	0.302	< 0.001
Daily living activities	0.319	< 0.001
Social function	0.435	< 0.001
Mental health	0.439	< 0.001

GLFS-25: 25-question Geriatric Locomotive Function Scale.

DISCUSSION

StD, a prevalent yet long-overlooked issue in oncological practice, holds significant prognostic value if identified early. This study investigates the interplay between musculoskeletal and mental health (via LS) in elderly cancer patients, distinguishing itself from prior research focused solely on major depressive disorders.

Prevalence and factors influencing LS among elderly cancer patients

In the context of universal health promotion and population aging, maintaining and improving musculoskeletal function, prolonging independent living, and reducing the caregiving burden on families and society have become critical concerns in Chinese society[18]. Compared with diagnoses such as osteoporosis and sarcopenia, LS encompasses interactions among musculoskeletal function, physical capability, body composition, and overall health status, thereby enabling more effective identification of functional decline and related risks, and facilitating early intervention to prevent or reverse adverse health outcomes[19]. In this study, the incidence of LS among elderly cancer patients was 56.5%, consistent with previous findings from our research team but lower than the rates reported for Japanese cancer patients[2,5]. This discrepancy may be attributable to the fact that the current study enrolled elderly cancer patients attending routine follow-ups who maintained independent living, thereby exhibiting relatively better physical function compared to elderly cancer patients undergoing hospitalization for intensive anticancer treatment.

This study showed that advanced age, presence of tumor metastasis, lack of regular exercise habits, and StD were significant factors associated with LS in elderly cancer patients (P < 0.05). With increasing age, musculoskeletal function progressively declines, accompanied by a higher prevalence of conditions such as osteoarthritis and osteoporosis, which directly impair motor function and predispose elderly cancer patients to LS[19]. Patients with metastatic cancers typically experience more severe disease progression and tumor-related complications. Malignant tumors often cause functional impairments in affected organs and tumor-related cachexia, necessitating more aggressive interventions that further deplete the musculoskeletal system[2]. Regular exercise is typically indicative of better overall health. This study demonstrated a lower incidence of LS among elderly cancer patients with established exercise routines, highlighting the importance of promoting regular physical activity, even low-intensity exercise over extended periods, to sustain independent living[20,21]. In summary, active management of tumor progression, promotion of regular exercise, and timely monitoring of LS are essential to enhance musculoskeletal function and sustain independence among elderly cancer patients.

Prevalence of and factors influencing StD among elderly cancer patients

Depression is a common mental health concern among elderly cancer patients, significantly impairing their daily functioning and quality of life[6]. In this study, the prevalence of StD among elderly cancer patients was 38.7%, with those having three or more chronic diseases exhibiting a 3.521-fold greater incidence of StD compared to those without chronic diseases (P < 0.001). Zhou et al[22] reported that elderly individuals with chronic conditions have a higher risk of depression, and this risk increases proportionally with the number of chronic illnesses. Barnett et al[23] similarly found an elevated prevalence of mental health disorders among individuals with multiple chronic conditions. Moreover, previous studies have demonstrated poorer mental health among cancer patients compared to the general population[24]. Elderly individuals with chronic diseases often experience anxiety, depression, feelings of hopelessness, and even suicidal ideation due to the prolonged duration of their illness, gradual functional decline, and reduced capacity for self-care[25]. Compared to intervening after the onset of clinical depression, early identification and management of pre-depressive states can effectively prevent further psychological deterioration while conserving healthcare resources. Therefore, healthcare providers are encouraged to routinely screen elderly cancer patients for StD, offer targeted psychological counseling, and provide mental health education, thereby alleviating their psychological burden and enhancing their overall mental well-being.

Positive correlation between LS and StD in elderly cancer patients

Musculoskeletal function is significantly related to mental health status[26]. This study showed that the total GLFS-25 score and its 4 dimensions-pain, ability to perform activities of daily living, social functioning, and mental health-were positively correlated with StD scores in elderly cancer patients (P < 0.05). This suggests a bidirectional relationship between LS and StD, creating a vicious circle. The study further indicated that elderly cancer patients with concurrent LS had a 3.102 times greater risk of developing StD than those without LS (P < 0.05), suggesting that elderly cancer patients with comorbid LS experience impaired daily functioning and reduced social engagement due to aging, tumor progression, and anti-tumor treatments, thereby seriously compromising their mental health[27,28]. This association may be attributed to elderly cancer patients requiring prolonged medical treatment alongside declining physical function, resulting in increased concerns about disease prognosis and escalating medical expenses, thus intensifying psychological stress[29].

Depression diagnosis and elevated depressive symptoms were also notably linked to LS. Specifically, this study revealed that elderly cancer patients with StD had a 3.228 times greater incidence of LS than those without StD (P < 0.05). Depression is a common affective disorder among elderly cancer patients, contributing to diminished physical functioning, heightened treatment difficulties, and increased mortality rates[28,30]. This relationship may arise because depressive symptoms-such as depressed mood, slowed cognitive processing, and reduced motivation-lead to impaired balance and responsiveness, subsequently decreasing daily activity levels and eventually contributing to LS development.

Clinicians should implement close surveillance of musculoskeletal function and psychological well-being in elderly cancer patients as an integral component of their primary treatment regimen. Systematic evaluation of LS and StD through standardized assessment protocols is strongly recommended for this patient population. Additionally, while addressing tumor progression and managing comorbid conditions, healthcare providers should actively promote the adoption of regular exercise routines and facilitate guidance for appropriate moderate physical activity. These multidisciplinary interventions are designed to holistically mitigate the risks associated with LS and StD, thereby optimizing quality of life outcomes in elderly oncology patients.

Limitations

This study had several limitations. It was conducted as a single-center cross-sectional survey at the Department of Oncology of the Affiliated Hospital of Jiangnan University, lacking multicenter validation and subgroup analyses for different tumor types. Future research should involve a broader population and include subgroup analyses based on tumor classification. While recognizing the inherent limitations of cross-sectional designs in determining causality between LS, StD, and comorbid conditions, we are initiating a prospective cohort study to elucidate the temporal and potentially causal relationships among these variables. These approaches would enhance the generalizability of the findings and provide stronger evidence for improving the musculoskeletal and psychological conditions of elderly cancer patients.

CONCLUSION

Elderly cancer patients exhibit a high incidence of LS and StD, conditions that mutually affect each other. Therefore, governments, society, and families should prioritize the musculoskeletal function and psychological health of elderly cancer patients. Efforts should include enhancing patient education on LS and StD through health promotion programs and providing comprehensive social and familial support to aid rehabilitation, thereby improving both motor function and mental health outcomes.