Medires Publishers - Article

Mental health in older adults has become a major public health concern due to the growing aging population. This psychological well-being goes beyond the absence of psychiatric disorders to encompass key subjective dimensions such as self-esteem, self-perception, and a sense of social usefulness.
Among these dimensions, self-esteem occupies a central place in psychology and is considered a cornerstone of personal well-being. According to Rosenberg (1965), it refers to a global attitude-positive or negative-that an individual holds toward themselves [1]. It reflects how people evaluate their self-worth and their right to be respected. Closely tied to how individuals perceive themselves in social and professional roles, self-esteem plays a key role in older adults’ ability to adapt to age-related changes. In general, older individuals with strong self-confidence tend to exhibit higher self-esteem, which helps them better cope with psychosocial challenges.
More recently, Orth and Robins emphasized that self-esteem refers to the intrinsic value a person attributes to themselves, independent of external achievements or social recognition [2]. This concept has inspired numerous studies, focusing on its development during childhood and adolescence, the factors influencing its evolution, its consequences, and interventions to address low self-esteem.
Although early research predominantly focused on younger populations, self-esteem has gradually been integrated into the study of psychological aging. It is now recognized as a key factor in older adults’ adjustment processes related to aging.
In this context, our study pursued two main objectives:

• To estimate the prevalence of low self-esteem among older patients consulting in general practice, using a validated measurement tool (the Rosenberg Self-Esteem Scale);
• To identify and analyze the sociodemographic, medical, functional, and contextual factors associated with low self-esteem.

General Characteristics of the Sample
The study included a sample of 60 elderly patients with a mean age of 68 years, ranging from 62 to 76 years, and a standard deviation of 4.8 years—indicating a relatively homogeneous population in terms of age. The gender distribution showed a slight female predominance, with a sex ratio of 0.87 (28 men and 32 women).
From a social perspective, more than half of the participants lived with their spouse, suggesting the preservation of emotional and family bonds. Approximately one-third were retired, reflecting that a significant portion had already transitioned out of professional activity. Additionally, 76.7% of patients lived in their own home, which may act as a protective factor for autonomy and psychological stability.

Health Status and Autonomy
In terms of medical history, 53.3% of participants reported two to three chronic conditions, indicating a high level of comorbidity in this age group. Furthermore, 20% reported a history of falls, which are known to have repercussions on both autonomy and self-esteem. More than half of the patients experienced two to three hospitalizations, reflecting a certain degree of medical frailty.
Functionally, 43.3% of the subjects had reduced autonomy, as assessed by the Katz Index. This limitation in activities of daily living (ADLs) is often a source of self-devaluation and may negatively impact one’s sense of personal efficacy.
Self-Esteem and Associated Factors
Self-esteem assessment, conducted using the Rosenberg Self-Esteem Scale, revealed that 40% of the patients exhibited low self-esteem. This significant proportion highlights the need to address psychological dimensions in the comprehensive care of older adults.

• The analysis of sociodemographic, medical, and contextual factors associated with low self-esteem identified several significant associations:
• Age > 70 years: strongly associated with low self-esteem (p < 0.0001), suggesting the impact of advanced aging on self-image.
• Widowed marital status: significantly more common among those with low self-esteem (p < 0.0001), highlighting the protective role of conjugal bonds.
• Low educational level (primary education or illiteracy): associated with low self-esteem, suggesting the influence of cultural capital on self-perception.
• Living with a descendant: correlated with lower self-esteem (p < 0.0001), likely reflecting a sense of dependency or loss of control.
• Retirement status: identified as a psychological vulnerability factor due to the disruption of socially valued roles.
• Loss of autonomy: strongly correlated with low self-esteem, confirming the critical role of functional independence in maintaining a positive self-image.

Prevalence of Low Self-Esteem
Self-esteem is a foundational concept in psychology. William James was one of the first to explore it, stating that self-evaluation is based on the gap between personal aspirations and achieved results [5]. This individual-centered approach was enriched by Cooley’s sociological perspective, which emphasized the importance of how others view us: according to him, the “looking-glass self” is constructed through the image one believes others have of them [6]. Thus, self-esteem is the result of a dual process-internal, based on personal feelings and standards, and external, based on perceived social recognition [6].
According to Ulrich Orth, the most widely used tool to assess global self-esteem is probably Rosenberg’s Self-Esteem Scale, developed by Rosenberg (1965) [7-8]. Its ten items represent a condensed balance between positive and negative statements, controlling response biases such as acquiescence [9]. This instrument has high reliability, with Cronbach’s alpha ranging from 0.77 to 0.88, and good test–retest reliability [10].
The simplicity and clarity of the RSES make it particularly suitable for older adults, especially those with cognitive or literacy difficulties [11]. However, while the RSES effectively measures global self-esteem, it does not clearly reflect age-specific aspects such as health, independence, or transitions in social roles, which are especially important in the elderly [12]. Targeted research is needed to understand self-esteem as a dynamic construct that develops throughout life.
Our study reveals that 40% of older patients interviewed reported low self-esteem. This proportion varies by age: 3.3% among those aged 60–70, and 36.6% among those aged 70–80, reflecting a marked decline with advancing age.
The issue of self-esteem development in aging has prompted many studies. Our results are confirmed by Orth’s study, which identified a quadratic trajectory of self-esteem across adulthood: an increase up to the sixties, followed by a progressive decline [7].
This decline could be explained by several factors, notably the onset of chronic illnesses, loss of autonomy, and cognitive impairments associated with this age group.
Other longitudinal studies conducted by Orth et al., show that self-esteem increases until the age of 60–70, then gradually declines [13].
According to Dorota Ryszewska, self-esteem develops from both positive and negative life experiences. The most significant increase in self-esteem occurs during childhood and adulthood, peaking around age 60–70, and then gradually decreasing with age [14]. Changing roles may explain this, especially when considering factors such as children leaving home, retirement, financial difficulties, declining health, reduced family involvement, and insufficient social support. This can stem from decreased physical and mental function, deteriorating social status and finances, and the loss of loved ones.
Likewise, a longitudinal study by Trzesniewski et al. (2004) also showed that self-esteem significantly decreases between the ages of 70 and 80 [15].
However, other research, such as that conducted in Japan by Ogihara, emphasizes that this decline is not systematic and can be influenced by sociocultural context [12].
Furthermore, several authors suggest that self-esteem is not solely linked to chronological age, but also depends on factors such as social integration, adaptability to life events (illness, bereavement, retirement), and subjective self-perception [16-19].

The Role of Psychosocial Determinants
Several psychosocial determinants influence this dynamic. In our study, low self-esteem was associated with widowhood, living with a descendant, low educational level, retirement, and loss of autonomy.
Education level plays a crucial role. Some studies indicate that a higher level of education contributes to better self-esteem, better understanding of aging-related changes, and more effective adaptation [20-21].
According to a Brazilian study, education was statistically associated with self-esteem, showing that older individuals with a higher level of education had proportionally higher self-esteem [22]. Education is a key determinant in accessing economic opportunities, using healthcare services, and participating in health promotion and protection programs. Moreover, economic stability and the perception of sufficient income are important predictors of high self-esteem. In the study population, no statistically significant association was identified between marital status and self-esteem in older adults. However, there is a greater tendency for older adults who are married or living together to have higher self-esteem, suggesting that sharing a cohabitation with a partner tends to establish a greater sense of security among them [22].
Marriage may exert a protective effect through various environmental, social, and psychological mechanisms, giving married individuals a better overall health status. Additionally, the expansion of social networks associated with marriage may facilitate access to information and healthcare, encourage positive health behaviors, and provide support in times of stress. These factors significantly influence health perception in older adults.
In the study by Dorota Ryszewska-Łabędzka, the main correlates of low self-esteem were having less than secondary education, the presence of a caregiver, and precarious financial situations [14]. Occupational status also acts as an indicator: a paid, stable, and rewarding job supports autonomy and enhances self-esteem. It ensures better living conditions, healthcare access, and a more active social network.
The social environment also plays a key role. Living at home seems protective, particularly in allowing the maintenance of decision-making autonomy [23]. However, this depends heavily on housing conditions and the level of social isolation. In contrast, an institutional setting, despite medical supervision, can limit social recognition and negatively impact self-image [24].
Indeed, loneliness and isolation frequently affect older people and harm their self-esteem, thus reducing their quality of life [25-27]. Moreover, loneliness can lead to serious health problems; therefore, it is crucial for older individuals to maintain interpersonal relationships, especially with family [22,25,28,29,30,31].
The study conducted by Šare, S. showed lower self-esteem (p = 0.002) among institutionalized elderly people compared to those living at home, and no correlation between self-esteem and sociodemographic factors such as age, sex, or social environment. Widowhood was the only sociodemographic variable negatively associated with self-esteem and confirmed as a negative predictor [25].
Compared to older adults living in their own homes, those in nursing homes reported lower self-esteem, higher levels of depression, and more anxiety. This may be explained by the fact that nursing home residents were older than those living with family and had higher rates of depression and lower self-esteem.
This study confirms the links between self-esteem, anxiety, and depression in the elderly. It suggests that low self-esteem is associated with higher levels of depression, which increases with age [25].
Male gender and institutional living may be predictive factors for anxiety, while widowhood can also impact self-esteem. This can lead to negative consequences for the mental health of older people, especially those in institutional settings [25].
According to Alaphilippe, self-esteem is an indicator of mental health, personality maturity, and adaptive capacity [24]. Thus, low self-esteem is closely linked to low life satisfaction, loneliness, depression, and anxiety [32].

Loss of Autonomy: A Central Factor
One of the most critical factors affecting self-esteem in older adults is the loss of autonomy. Our study confirms that loss of autonomy is one of the most crucial determinants of low self-esteem. It limits the ability to engage in meaningful activities, reduces opportunities for social recognition, and weakens the sense of usefulness.
This loss is often exacerbated by chronic illnesses, repeated hospitalizations, cognitive disorders, and mood disorders. It profoundly affects quality of life and self-perception [32,33,34-36]. It can also lead to asymmetric dependency on caregivers, sometimes perceived as a threat to dignity, especially in institutional settings [37].
Sensory disorders (vision, hearing, speech) restrict social interaction and impair functional independence, thus increasing the risk of diminished self-esteem [38]. Added to this are functional impairments (shortness of breath, sleep disturbances, incontinence, chronic pain, overweight) [39-40]. These issues are often identified as factors limiting independence and deteriorating self-esteem in older adults.
The most common sources of disability are conditions resulting from chronic diseases and comorbidities. In turn, functional limitations and perceived ailments negatively affect mood and self-esteem [13,41]. The level of independent functioning largely depends on mood. It is important to note that depressed mood, especially clinical depression, is significantly associated with low self-esteem [25,42,29,30].
Conversely, adaptation to illness is also influenced by self-compassion, which facilitates the acceptance of pain and other ailments or imperfections, enabling individuals to take care of themselves [42].
Thus, the ability to function independently remains a major determinant of quality of life and self-esteem. Low independence significantly reduces self-esteem [43,44,45].
Because independence fosters healthy self-esteem, the support offered should promote actions aimed at improving and creating environments conducive to maintaining autonomy in older adults.
Finally, loss of autonomy appears not only as a trigger for declining self-esteem, but also as an obstacle to its restoration. This observation calls for a reconsideration of support methods, promoting the participation of older people in decisions that concern them and valuing residual forms of autonomy.

Digital Literacy and Self-Esteem: An Emerging Relationship
A recent field of research explores the link between digital literacy and self-esteem. The study by Wenjie Zhu shows that mastering digital tools improves self-efficacy, fosters social participation, and strengthens the sense of autonomy [46]. Conversely, the digital divide increases feelings of exclusion, frustration, and loss of self-confidence. These findings suggest that technology can play a major role in the psychological resilience and social integration of older adults [46].
In the same vein, the application of artificial intelligence to aging opens new perspectives: detecting domestic risks, sending alerts in case of incidents, monitoring health status, and helping older adults better manage their daily lives (e.g., scheduling reminders for medication or injections, medical appointments, tasks to be completed, and mealtimes). These technological innovations could actively contribute to preserving autonomy and improving self-esteem in older adults by promoting aging in place under safe and dignified conditions.