Depressive symptoms and cognitive impairment among rural Chinese older women: anxiety and poor sleep as sequential correlates—A cross-sectional analysis

Background Depressive symptoms are a well-established predictor of late-life cognitive impairment. Furthermore, anxiety and sleep quality—both correlates of cognitive impairment—could mediate the depression–cognition association in older women. Nevertheless, limited research has empirically tested this hypothesis using causal mediation analysis. Methods This cross-sectional study recruited 718 older women from rural areas of Sichuan, Chongqing, and Guizhou provinces in China using convenience sampling. Trained assessors administered the Patient Health Questionnaire-9, the Chinese Version of the Montreal Cognitive Assessment, the Generalized Anxiety Disorder-7 Scale, and the Pittsburgh Sleep Quality Index to assess depressive symptom severity, cognitive performance, anxiety levels, and sleep quality, respectively. Statistical analyses were performed using SPSS 29.0, with chi-square testing, Spearman rank correlation, and bootstrapped mediation analysis (5,000 resamples, bias-corrected) executed through the PROCESS macro (version 4.1). Results Both direct and indirect effects of depressive symptoms on cognitive impairment were found in older women in rural areas ( p 0.05). As predicted, anxiety and sleep quality mediated the relationship between depressive symptoms and cognitive impairment B Anxiety = −0.580, 95% confidence interval (CI): −0.737 to −0.420; B sleep quality = −0.168, 95% CI: −0.239 to −0.101. In addition, serial mediation analyses indicated that the association of depressive symptoms and cognitive impairment was mediated by anxiety and sleep quality in a sequential manner ( B = −0.059, 95% CI: −0.122 to −0.008). Conclusion This study identified a modifiable pathway in older rural Chinese women: anxiety and sleep quality sequentially mediated the link between depressive symptoms and cognitive impairment, with anxiety showing an association with sleep disturbances that correlated with greater impairment. Multicomponent strategies addressing this symptom triad suggest intervention targets to mitigate the risk of decline in this underserved population.