Association of Sleep with Anxiety in Chinese Empty-Nest Older Adults: The Mediating Roles of Physical Exercise and Social Participation

Sleep disturbances are common among older adults and are often closely associated with anxiety symptoms, which together can substantially compromise physical and mental health.A cross-sectional analysis was conducted using data from the 2017/2018 wave of the Chinese Longitudinal Healthy Longevity Survey (CLHLS). The study included 6,106 Chinese older adults (aged ≥ 65 years) living in empty-nest households. Physical exercise was measured based on self-reported regular engagement in exercise, and social participation was defined as involvement in organized social activities (e.g., community or group-based events). Associations between sleep quality and duration and anxiety were estimated using multivariable logistic regression, and mediation effects of physical exercise and social participation were tested using bootstrap resampling.Among the 6,106 participants, 593 (9.7%) reported anxiety symptoms. Multivariable logistic regression analysis indicated that poor sleep quality was significantly associated with a higher risk of anxiety (OR = 3.23, 95% CI: 2.62–4.01, P< 0.001). Short sleep duration was also an independent risk factor for anxiety (OR = 1.34, 95% CI: 1.04–1.74, P= 0.025), whereas long sleep duration showed no significant association. Subgroup analyses stratified by sex, marital status, and economic status consistently revealed significant associations between sleep (both quality and duration) and anxiety, with no statistically significant interactions observed. Mediation analyses demonstrated that physical exercise significantly mediated the relationships of both sleep quality and long sleep duration with anxiety (all P < 0.01, with bootstrap confidence intervals excluding zero). Similarly, social participation significantly mediated the relationships of both short and long sleep duration with anxiety (all P < 0.01, with bootstrap confidence intervals excluding zero).In Chinese empty-nest older adults, both poor sleep quality and short sleep duration are independent risk factors for anxiety symptoms, with sleep quality exerting a stronger influence. Physical exercise partially mediated the associations between sleep quality and anxiety and between long sleep duration and anxiety, whereas social participation mediated the association between sleep duration (short and long) and anxiety. Improving sleep quality and ensuring adequate sleep duration may help reduce anxiety risk, and interventions promoting physical exercise and social participation could enhance these protective effects.