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The interrelationships among insomnia, frailty, anxiety, and cognitive function in middle-aged and older adults: a
Xue-Qiao Wang1, Yan-Xin Wang1, Zhao-Hao Ye1
1Department of Neurology, The First Affiliated Hospital of Anhui University of Chinese Medicine, Hefei, China.
Objective:
This study examined the complex relationships among insomnia, anxiety, frailty, and cognitive function in middle-aged and older adults, testing whether frailty moderates the mediating role of anxiety between insomnia and cognition.
Methods:
This cross-sectional study included 108 insomnia patients recruited from community and hospital settings between August 2025 and February 2026. Assessments included the Pittsburgh Sleep Quality Index, FRAIL Scale, Montreal Cognitive Assessment-Basic, and Hamilton Anxiety Rating Scales. Moderated mediation analysis was conducted using the PROCESS macro (Model 7).
Results:
Pre-frailty significantly moderated the insomnia-anxiety relationship (PSQI × Pre-frailty: β = 1.029, p = 0.017). The indirect effect of insomnia on cognition through anxiety was significant in both robust (β = -0.053, 95% CI [-0.111, -0.004]) and pre-frail individuals (β = -0.090, 95% CI [-0.179, -0.007]), with a significant index of moderated mediation (Index = -0.037, 95% CI [-0.101, -0.0003]), indicating that the anxiety-mediated pathway was stronger in pre-frail individuals. Both frailty (β = -1.3, p < 0.001) and insomnia severity (β = -0.176, p < 0.001) independently predicted cognitive function.
Conclusion:
The anxiety-mediated pathway between insomnia and cognitive impairment is active in both robust and pre-frail individuals but is significantly amplified in the pre-frail state, identifying pre-frailty as a distinct psychologically vulnerable window. Integrated interventions targeting insomnia, anxiety, and pre-frailty may be particularly beneficial for preserving cognitive health in middle-aged and older adults.
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