Abstract

The objective of this study was to analyze the prevalence of vulnerability and associated factors among older people using family health strategies in Várzea Grande, Brazil. A cross-sectional study was performed with 377 community-dwelling older people. The dependent variable, vulnerability, was assessed using the Vulnerable Elders Survey. The independent variables included sociodemographic characteristics and the health status of the study population assessed using the following validated instruments: the Mini-Mental State Examination; Katz ADL scale and Lawton and Brody IADL scale; Geriatric Depression Scale; and Mini Nutritional Assessment Short-Form. Bivariate analysis was conducted using the Mantel-Haenszel chi-squared test with prevalence ratios and multivariate analysis was performed using Poisson regression. The data showed that 49% of the study population were vulnerable. The variables that showed the strongest association with vulnerability were dependence in IADLs (PR = 4.43), presence of depressive symptoms (PR = 1.34), and being aged 80 and over (PR = 1.34). The prevalence of vulnerability found by the present study was high when compared to other studies with community-dwelling older people. The VES-13 was shown to be easy to use in primary healthcare settings and particularly practical for screening vulnerability among older people.

Key words
Aging; Vulnerable populations; Older people

Introduction

Population aging is a worldwide phenomenon and is growing faster in developing countries. In 1950, there were around 205 million people aged 60 years and over. In 2012, this figure had increased to almost 810 million and is expected to more than double to over 2 billion by 2050¹1 Fundo de População das Nações Unidas (UNFPA). Envelhecimento no Século XXI: Celebração e Desafio. Nova York: UNFPA e Help Age International; 2012..

In Brazil, the pace of population aging has been faster than the global average¹1 Fundo de População das Nações Unidas (UNFPA). Envelhecimento no Século XXI: Celebração e Desafio. Nova York: UNFPA e Help Age International; 2012.. In 2000, there were 14.2 million older people. This figure increased to 19.6 million in 2010 and is expected to rise to 41.5 million in 2030 and 73.5 million in 2060²2 Instituto Brasileiro de Geografia e Estatística (IBGE). Mudança Demográfica no Brasil no Início do Século XXI: subsídios para as projeções da população. Rio de Janeiro: IBGE; 2015.. This poses major challenges for health professionals and healthcare services and requires the development of new forms of healthcare and monitoring for this population group. As a result, protection and care actions tailored towards this group have assumed a prominent position in the public agenda.

A number of factors influence healthy ageing, including physical and mental health status, financial independence, control and prevention of chronic diseases, and the existence of social support³3 Brasil. Ministério da Saúde (MS). Envelhecimento e saúde da pessoa idosa. Brasília: MS; 2006..

The morphological, functional, biochemical and psychological changes that take place during aging can make older people vulnerable due to a reduction in their capacity to adapt to their environment⁴4 Papaléo Netto M. O estudo da velhice: Histórico, Definição do Campo e Termos Básicos. In: Freitas EV, Py L, organizadores. Tratado de Geriatria e Gerontologia. 3ª ed. Rio de Janeiro: Guanabara Koogan; 2011. p. 3-13.. Thus, identifying vulnerable groups in the elderly population enables the formulation of effective policies and strategies to prevent undesirable outcomes and promote recovery from disabilities. The Vulnerable Elders Survey (VES-13)is an assessment instrument developed to identify older people at risk of health deterioration or death, where vulnerability is defined as increased risk of functional decline or death⁵5 Saliba D, Elliott M, Rubenstein LZ, Solomon DH, Young RT, Kamberg CJ, Roth C, MacLean CH, Shekelle PG, Sloss EM, Wenger NS. The Vulnerable Elders Survey: a tool for identifying vulnerable older people in the community. J Am Geriatr Soc 2001; 49(12):1691-1699.. Studies have shown that the version adapted and validated for use in Brazil was easily understood and accepted by older people and has consistent and adequate psychometric properties⁶6 Luz LL, Santiago LM, Silva JFS, Mattos IE. Primeira etapa da adaptação transcultural do instrumento The Vulnerable Elders Survey (VES-13) para o Português. Cad Saude Publica 2013; 29(3):621-628.^,77 Luz LL, Santiago LM, Silva JFS, Mattos IE. Psychometric properties of the Brazilian version of the Vulnerable Elders Survey-13 (VES-13). Cad Saude Publica 2015; 31(3):507-515..

With a view to gaining a better understanding of this phenomenon, the aim of the present study was to determine the prevalence of vulnerability and identify associated factors among community-dwelling older people using primary healthcare services in Várzea Grande in the State of Mato Grosso, Brazil.

Methods

A cross-sectional study was conducted with people aged 60 years and over registered in family health strategies (Estratégias de Saúde da Família- ESF)in Várzea Grande, located in the Metropolitan Region of Cuiabá in the State of Mato Grosso. The study was conducted in accordance with the ethical standards and procedures for research with human beings set out in Resolution 466/2012issued by the National Health Council and approved by the Research Ethics Committee at Júlio Müller University Hospital in Cuiabá (application Nº 1.243.299).

Eleven ESFs were selected from the 15 ESFs in Várzea Grande using cluster sampling. The sample size was divided proportionally among the selected ESFs according to the number of older people registered in each ESF. Sample size was calculated using the procedures proposed for finite populations⁸8 Luiz RR, Magnanini MMF. A lógica da determinação da amostra em investigação epidemiológica. Cad Saúde Colet 2000; 8(2):9-28., adopting a 95% confidence level, tolerable sampling error of 0.05, and assumed prevalence of 0.50. The resulting sample size was increased by 10% to compensate for potential losses. Older people with cognitive impairment, suffering the effects of a stroke, or with a severe vision, language, or hearing impairment were excluded from the sample. Refusals, respondents who were not at home at the time of the visit to conduct the interview, and individuals who met the above exclusion criteria were replaced by the closest resident registered in the ESF. Cognitive impairment was assessed using the version of the Mini-Mental State Examination adapted for use in Brazil, adopting two cut-off points according to level of schooling⁹9 Lourenço RA, Veras RP. Mini-Exame do Estado Mental: características psicométricas em idosos ambulatoriais. Rev Saude Publica 2006; 40(4):712-719.. A total of 213 older people with cognitive impairment and 30 refusals were excluded and replaced. The final sample comprised 377 older people. All respondents signed an informed consent form.

Data was collected between March and June 2016 using structured interviews conducted in the respondents’ homes by previously trained and standardized interviewers.

The dependent variable was vulnerability, which was assessed using the Brazilian version⁶6 Luz LL, Santiago LM, Silva JFS, Mattos IE. Primeira etapa da adaptação transcultural do instrumento The Vulnerable Elders Survey (VES-13) para o Português. Cad Saude Publica 2013; 29(3):621-628.^,77 Luz LL, Santiago LM, Silva JFS, Mattos IE. Psychometric properties of the Brazilian version of the Vulnerable Elders Survey-13 (VES-13). Cad Saude Publica 2015; 31(3):507-515. of the VES-13, developed to identify persons aged 65 years and older at increased risk of death or functional decline⁵5 Saliba D, Elliott M, Rubenstein LZ, Solomon DH, Young RT, Kamberg CJ, Roth C, MacLean CH, Shekelle PG, Sloss EM, Wenger NS. The Vulnerable Elders Survey: a tool for identifying vulnerable older people in the community. J Am Geriatr Soc 2001; 49(12):1691-1699.. This13-item questionnaire considers age, self-rated health, functional capacity, and physical condition. Scores range from 0 to 13, where the cut-off point for vulnerability is greater than or equal to 3⁵5 Saliba D, Elliott M, Rubenstein LZ, Solomon DH, Young RT, Kamberg CJ, Roth C, MacLean CH, Shekelle PG, Sloss EM, Wenger NS. The Vulnerable Elders Survey: a tool for identifying vulnerable older people in the community. J Am Geriatr Soc 2001; 49(12):1691-1699..

Theindependent variables were the following sociodemographic characteristics: sex (male,female);age group (60 to 69 years,70 to 79 years, and80 years and over);per capita income (up to half a minimum salary, between half and one minimum salary, > one minimum salary);race/skin color (brown, black, and white);family situation (living with someone; living alone); and marital status (living with partner; living without partner). Level of schooling, originally obtained from the questions Do you know how to read or write a simple note?”and “what level of schooling do you have?, was reclassified as “literate” or “illiterate”, due to the generally low level of education of the study population. The following dimensions of health status were also investigated: ability to perform activities of daily living (independent; dependent), ability to perform instrumental activities of daily living (independent; dependent), depression (without depressive symptoms; with depressive symptoms), nutritional status (malnutrition/at nutritional risk; without nutritional risk), comorbidity (without comorbidity with severity level 3 or 4; with comorbidity with severity level 3 or 4), and polypharmacy(yes; no).

Ability to perform activities of daily living (ADLs)and instrumental activities of daily living(IADLs) was assessed using the Katz ADL scale and Lawton and Brody IADL scale, respectively, both adapted and validated for use in Brazil¹⁰10 Lino VTS, Pereira SEM, Camacho LAB, Filho STR, Buksman S. Adaptação transcultural da Escala de Independência em Atividades da Vida Diária (Escala de Katz). Cad Saude Publica 2008; 24(1):103-112.^,1111 Santos RL, Virtuoso Júnior JS. Confiabilidade da versão brasileira da escala de atividades instrumentais de vida diária. Rev Bras Promoç Saude 2008; 21(4):290-296..Depression was assessed using the 15-item Geriatric Depression Scale (GDS-15)¹²12 Almeida OP, Almeida SA. Short versions of the geriatric depression scale: a study of their validity for the diagnosis of a major depressive episode according to ICD-10 and DSM-IV. Int J Geriatr Psychiatry 1999; 14(10):858-865., while nutritional status was assessed using theMini Nutritional Assessment Short-Form (MNA-SF)¹³13 Kaiser MJ, Bauer JM, Ramsch C, Uter W, Guigoz Y, Cederholm T, Thomas DR, Anthony P, Charlton KE, Maggio M, Tsai AC, Grathwohl D, Vellas B, Sieber CC. Validation of the Mini Nutritional Assessment Short-Form (MNA-SF): a practical tool for identification of nutritional status. J Nutr Health Aging 2009; 13(9):782-788.. Comorbidity was evaluated using theCumulative Illness Rating Scale for Geriatrics (CIRS-G)¹⁴14 Miller MD, Paradis CF, Houck PR, Mazumdar S, Stack JA, Rifai AH, Mulsant B, Reynolds III CF. Rating chronic medical illness burden in geropsychiatric practice and research: application of the Cumulative Illness Rating Scale. Psychiatry Res 1992; 41(3):237-248.. Polypharmacy was defined as the continued use of five or more medications¹⁵15 Carlson JE. Perils of polypharmacy: 10 steps to prudent prescribing. Geriatrics 1996; 51(7):26-35.. Medication use was self-reported; however, to minimize recall bias, respondents were asked to show the medication labels or prescriptions.

The questionnaires were coded and the data was double entered into the software program Epi Info version 3.5.2.. Data entry errors detected by the application Data Compare were corrected. Statistical analysis was undertaken using Stata version 13.0.

The descriptive analysis of the above characteristics of the study population was performed using absolute and relative frequencies for the categorical variables and mean, median, and standard deviations for the numerical variables. Bivariate analysis was conducted using the Mantel-Haenszel chi-squared test and prevalence ratios (with CI 95%) to measure the association between the dependent variable(vulnerability) and independent variables.

For multivariate analysis, Poisson regression was used including the variables that showed ap-value of < 0.20. An explanatory model was used maintaining all statistically significant variables (p ≤ 0.05).

Results

The average age of the study population was 69.6 (± 7.5) years. The majority of the sample were women (60.2%), aged between 60 and 69 years (56.8%), and declared themselves brown(59.2%). Approximately 44% of respondents did not have a partner and 72% were illiterate. Over half the sample (56%) had a per capita income of between half and one minimum salary (Table 1).

The data showed that prevalence of vulnerability was 49%. Our findings also showed that while 72.7% of the respondents were independent in ADLs, 62.3%were dependent in IADLs. In relation to the other dimensions investigated by this study, 68.7% of respondents did not have depressive symptoms, 60.5% did not have a severe comorbidity, 54.4% were not at nutritional risk, and 78.3%did not use multiple medications (Table 2).

The results of the bivariate analysis (Table 3) show that the likelihood of vulnerability was greater among women, respondents aged 80 years and over, and those who were illiterate. These associations were statistically significant (PR = 1.41, CI95% 1.12-1.78; PR = 1.81,CI95% 1.44-2.27; and PR = 1.50,CI95% 1.23-1.83, respectively) (Table 3).

With regard to health status (Table 4), the findings show that the likelihood of vulnerability was greater among respondents who demonstrated deficits in the six dimensions investigated. Statistically significant associations were found for being dependent in ADLs (PR = 1.62, CI95% 1.33-1.96) and IADLs (PR = 4.99, CI95% 3.29-7.55), presence of depressive symptoms (PR = 1.87, CI95% 1.54-2.26), being at nutritional risk/malnourished (PR = 1.31, CI95% 1.07-1.61), having a severe comorbidity (PR = 1.33, CI95% 1.09-1.63), and using multiple medications (PR = 1.30, CI95% 1.04-1.61).

In the multivariate model, statistically significant associations were maintained between vulnerability and being 80 years and over, dependence in IADLs, and presence of depressive symptoms (PR = 1.32, CI95% 1.07-1.63; PR = 4.12, CI95% 2.69-6.33; and PR = 1.29, CI95% 1.10-1.52, respectively) (Table 5).

Discussion

The data presented show a high overall prevalence of vulnerability, showing that almost half the patients were vulnerable. A study realized in João Pessoa (Paraíba) with a study population with similar characteristics to that of the present study and also using the VES-13 reported a slightly higher vulnerability prevalence rate (52.2%)¹⁶16 Barbosa KTF. Vulnerabilidade física, social e programática de idosos atendidos na Atenção Primária de Saúde do município de João Pessoa, Paraíba [dissertação]. João Pessoa: Universidade Federal da Paraíba; 2015.. A study that assessed the validity of the VES-13 conducted in the United States with 6,205 community-dwelling older peopleaged65 years and over reported a prevalence rate of 32.3%⁵5 Saliba D, Elliott M, Rubenstein LZ, Solomon DH, Young RT, Kamberg CJ, Roth C, MacLean CH, Shekelle PG, Sloss EM, Wenger NS. The Vulnerable Elders Survey: a tool for identifying vulnerable older people in the community. J Am Geriatr Soc 2001; 49(12):1691-1699., while a study undertaken in Ireland with 2,033 community-dwelling older people showed a prevalence rate of 32.1%¹⁷17 McGee HM, O'Hanlon A, Barker M, Hickey A, Montgomery A, Conroy R, O'Neill D. Vulnerable older people in the community: relationship between the Vulnerable Elders Survey and health service use. J Am Geriatr Soc 2008; 56(1):8-15.. It is interesting to note that the vulnerability prevalence rates observed in the present study and that conducted in João Pessoa are higher than those reported by the studies in Ireland and the United States, despite the fact that the former involved a younger age group(individuals aged 60 years and over).

This difference may be partially explained by differences in socioeconomic conditions between developed and developing countries, bearing in mind that health status is influenced by socioeconomic factors and the context of people’s lives¹⁸18 Néri AL, Achioni M. Velhice bem-sucedida e educação. In: Néri AL, Debert GG, organizadores. Velhice e sociedade. São Paulo: Papirus; 1999. p. 113-140..

Other possible explanations include the poor sanitary conditions and health status of the study population. Várzea Grande’s Human Development Index is well below the average of the cities where the other studies were conducted¹⁹19 United Nations Development Programme (UNDP). Work for human development Briefing note for countries on the 2015 [serial on the internet] 2015 [cited 2016 Nov 02]. Available from: http://hdr.undp.org/sites/all/themes/hdr_theme/country-notes/USA.pdf
http://hdr.undp.org/sites/all/themes/hdr... , indicating poorer living conditions among the study population. Furthermore, it is well-known that healthcare in our country often leaves a lot to be desired and that access to primary and moderately and highly complex care is poorer in Brazil than in the other countries²⁰20 Souza ECF. Acesso e acolhimento na atenção básica: uma análise da percepção dos usuários e profissionais de saúde. Cad Saude Publica 2008; 24(Supl.):S100-S110.. In this respect, it is necessary to improve the quality of care and local health practices in order to ensure the early detection of health problems and risk factors associated with loss of functional capacity among older people²¹21 Caldas CP, Veras RP, Motta LB, Lima KC, Kisse CBS, Trocado CVM, Guerra ACLC. Rastreamento do risco de perda funcional: uma estratégia fundamental para a organização da Rede de Atenção ao Idoso. Cien Saude Colet| 2013; 18(12):3495-3506., given that the latter is strongly associated with vulnerability.

The association between vulnerability and dependence in ADLs and IADLs was expected. In this respect, the variable that showed the strongest association with vulnerability was dependence in IADLs. Generally, loss of functional capacity in IADLs, which are more complex functions, precedes dependence in ADLs, which develops later²²22 Rodrigues MAP, Facchini LA, Thumé E, Maia F. Gender and incidence of functional disability in the elderly: a systematic review. Cad Saude Publica 2009; 25(Supl. 3):464-547.^,2323 Santos AA, Pavarini SC. Functionality of elderly people with cognitive impairments in different contexts of social vulnerability. Acta Paul Enferm 2011; 24(4):520-526.. It is also important to note that IADLs and ADLs are collinear variables, given that both are measures of loss of functional capacity. A study conducted in the United States with older people undergoing treatment for prostate cancer and a study in Poland involving 864 hospitalized elderly patients reported an association between dependence in ADLs and vulnerability²⁴24 Mohile SG, Bylow K, Dale W, Dignam J, Martin K, Petrylac DP, Stadler WM, Rodin M. A pilot study of the Vulnerable Elders Survey-13 compared with the Comprehensive Geriatric Assessment for identifying disability in older patients with prostate cancer who receive androgen ablation. Cancer 2007; 109(4):802-810.^,2525 Kroc L, Socha K, Soltysik BK, Cies'lak-Skubel A, Piechocka-Wochniak E, Blaszczak R, Kostka T. Validation of the Vulnerable Elders Survey-13 (VES-13) in hospitalized older patients. European Geriatric Medicine 2016; 7(5):449-453.. Aging leads to a gradual, progressive decline in functional capacity and this decline is often the only change in health status identified in older people, particularly in healthier subjects²⁶26 Brito FC, Nunes MI, Yuaso DR. Multidimensionalidade em Gerontologia II: instrumentos de avaliação. In: Papaléo Netto M. Tratado de Gerontologia. 2ª ed. São Paulo: Atheneu; 2007. p. 133-147.. Determining the functional capacity of older people and classifying their degree of independence, autonomy, and quality of life²⁷27 Del Duca GF, Silva MC, Hallal PC. Incapacidade funcional para atividades básicas e instrumentais da vida diária em idosos. Rev Saude Publica 2009; 43(5):796-805. is therefore important for identifying vulnerable individuals.

The presence of depressive symptoms was also associated with vulnerability, corroborating the findings of other studies using the VES-13. A study conducted in Italy using the GDS reported a moderate correlation between the presence of depressive symptoms andvulnerability²⁸28 Luciani A, Ascione G, Bertuzzi C, Marussi D, Codecà C, Di Maria G, Caldiera SE, Floriani I, Zonato S, Ferrari D, Foa P. Detecting disabilities in older patients with cancer: comparison between Comprehensive Geriatric Assessment and Vulnerable Elders Survey-13. J Clinic Oncol 2010; 28(12):2046-2050.. Other studies have also shown an association between depressive symptoms andvulnerability¹⁷17 McGee HM, O'Hanlon A, Barker M, Hickey A, Montgomery A, Conroy R, O'Neill D. Vulnerable older people in the community: relationship between the Vulnerable Elders Survey and health service use. J Am Geriatr Soc 2008; 56(1):8-15.^,2929 Bell SP, Schnelle J, Nwosu SK, Schildcrout J, Goggins K, Cawthon C, Mixon AS, Vasilevskis EE, Kripalani S. Development of a multivariable model to predict vulnerability in older American patients hospitalised with cardiovascular disease. BMJ 2015; 5(8):1-8.. Depressive disorders constitute a distinct categorical entity or independent syndromes characterized by low mood. Among older people, these disorders are commonly attributed to the loss of physical and mental functions that invariably accompanies aging. It is therefore important to diagnose depression before it becomes more advanced³⁰30 Becattini AC. Baterias breves para avaliação cognitiva no diagnóstico diferencial de demência e depressão. In: Veras R, Lourenço R. Formação humana em Geriatria e Gerontologia. Rio de Janeiro: UnATI/UERJ; 2010. p. 238-242., when, together with the presence of vulnerability, it can lead to a deterioration in health status.

The multivariate model revealed an association between being aged 80 years and over and vulnerability. It is important to highlight that individuals aged 85 years and over are automatically classified as vulnerable because they come within the cut-off point set by the VES-13.Various studies have also reported that prevalence of vulnerability is greater in older age groups⁵5 Saliba D, Elliott M, Rubenstein LZ, Solomon DH, Young RT, Kamberg CJ, Roth C, MacLean CH, Shekelle PG, Sloss EM, Wenger NS. The Vulnerable Elders Survey: a tool for identifying vulnerable older people in the community. J Am Geriatr Soc 2001; 49(12):1691-1699.^,1717 McGee HM, O'Hanlon A, Barker M, Hickey A, Montgomery A, Conroy R, O'Neill D. Vulnerable older people in the community: relationship between the Vulnerable Elders Survey and health service use. J Am Geriatr Soc 2008; 56(1):8-15.^,3131 Luz LL. Avaliação multidimensional da saúde de idosos com câncer de próstata e o 'The Vulnerable Elders Survey 13' (VES-13) como instrumento de triagem em oncogeriatria [tese]. Rio de Janeiro: Escola Nacional de Saúde Pública Sérgio Arouca; 2015.. A population-based cohort study conducted with older people living in São Paulo using a different vulnerability assessment tool also showed that the prevalence of vulnerability was higher in older people aged80 years and over³²32 Maia FOM. Vulnerabilidade e envelhecimento: panorama dos idosos residentes no município de São Paulo - Estudo SABE [tese]. São Paulo: Universidade de São Paulo; 2011.. It is important to mention that older age groups are also more likely to show poorer scores in the other dimensions of overall health³³33 Balducci L, Colloca G, Cesari M, Gambassi G. Assessment and treatment of elderly patients with cancer. Surg Oncol 2010; 19(3):117-123..

Our findings show that the prevalence of vulnerability was higher among women. Population aging in Brazil is characterized by “feminization”³⁴34 Camarano AA, Kanso S. Envelhecimento da população brasileira: uma contribuição demográfica. In: Tratado de Geriatria e Gerontologia. 3ª ed. Rio de Janeiro: Guanabara Koogan; 2011. p. 58-73., where women tend to show worse health status, increased social isolation and are more likely to be widowed and have emotional disorders³⁵35 Lima LCV, Bueno CMLB. Envelhecimento e gênero: a vulnerabilidade de idosas no Brasil. Rev Saúde e Pesquisa 2009; 2(2):273-280.. A study undertaken in Ireland with community-dwelling older people¹⁷17 McGee HM, O'Hanlon A, Barker M, Hickey A, Montgomery A, Conroy R, O'Neill D. Vulnerable older people in the community: relationship between the Vulnerable Elders Survey and health service use. J Am Geriatr Soc 2008; 56(1):8-15. and another in the United States with hospitalized older persons with cardiovascular problems²⁹29 Bell SP, Schnelle J, Nwosu SK, Schildcrout J, Goggins K, Cawthon C, Mixon AS, Vasilevskis EE, Kripalani S. Development of a multivariable model to predict vulnerability in older American patients hospitalised with cardiovascular disease. BMJ 2015; 5(8):1-8. also showed that the prevalence of vulnerability was higher among women.

The data presented also show that the prevalence de vulnerability was higher among illiterate individuals, corroborating the findings of other studies²⁹29 Bell SP, Schnelle J, Nwosu SK, Schildcrout J, Goggins K, Cawthon C, Mixon AS, Vasilevskis EE, Kripalani S. Development of a multivariable model to predict vulnerability in older American patients hospitalised with cardiovascular disease. BMJ 2015; 5(8):1-8.^,3131 Luz LL. Avaliação multidimensional da saúde de idosos com câncer de próstata e o 'The Vulnerable Elders Survey 13' (VES-13) como instrumento de triagem em oncogeriatria [tese]. Rio de Janeiro: Escola Nacional de Saúde Pública Sérgio Arouca; 2015.. Education level is a determinant of health and studies have shown that people with a higher level of education typically have healthier life styles and are more likely to seek preventive healthcare³⁶36 Viegas APB, Carmo RF, Luz ZMP. Fatores que influenciam o acesso aos serviços de saúde na visão de profissionais e usuários de uma unidade básica de referência. Saude Soc 2015; 24(1):100-112.^,3737 Pellegrini Filho A, Buss PM, Esperidião MA. Promoção da Saúde e seus Fundamentos: Determinantes Sociais de Saúde, Ação Intersetorial e Políticas Públicas Saudáveis. In: Paim JS, Almeida-Filho N, organizadores. Saúde coletiva: teoria e prática. Rio de Janeiro: MedBook; 2014. p. 305-326.. It is important to stress that the level of education of the study population was generally low, thus preventing a stratified analysis according to education level to better explain the influence of this factor on vulnerability.

With regard to health status, the presence of comorbidity, nutritional risk, and multiple use of medications showed associations with vulnerability only in the bivariate analysis. However, other studies have reported a significant association in the same direction.

Researchers in Italy who used the CIRS-G and VES-13 to assess 419 individuals aged 70 years and over with cancer reported an association between comorbidity and vulnerability²⁸28 Luciani A, Ascione G, Bertuzzi C, Marussi D, Codecà C, Di Maria G, Caldiera SE, Floriani I, Zonato S, Ferrari D, Foa P. Detecting disabilities in older patients with cancer: comparison between Comprehensive Geriatric Assessment and Vulnerable Elders Survey-13. J Clinic Oncol 2010; 28(12):2046-2050.. Other studies using the VES-13 with different comorbidity assessment instruments also showed associations in the same direction²⁴24 Mohile SG, Bylow K, Dale W, Dignam J, Martin K, Petrylac DP, Stadler WM, Rodin M. A pilot study of the Vulnerable Elders Survey-13 compared with the Comprehensive Geriatric Assessment for identifying disability in older patients with prostate cancer who receive androgen ablation. Cancer 2007; 109(4):802-810.^,3838 Mangram AJ, Cornielle MG, Moyer MM, Stienstra A, Collins M, Chaliki S, Chaliki K, Stienestra S, Wycoff J, Veale K, Dzandu JK. Pre-injury VES-13 score at admission predicts discharge disposition for geriatric trauma patients. Ann Gerontol Geriatric Res 2014; 1(2):1010.. Comorbidity has also been shown to be an important predictor of other complications and adverse outcomes among older persons³⁹39 Kadam UT, Croft PR. Clinical multimorbidity and physical function in older adults: a record and health status linkage study in general practice. Fam Pract 2007; 24(5):412-419.. In this respect, a study in Brazil with 104 hospitalized older people found an association between comorbidity and increased risk of death after hospitalization⁴⁰40 Sousa-Muñoz RL, Ronconi DE, Dantas GC, Lucena DMS, Silva IBA. Impacto de multimorbidade sobre mortalidade em idosos: estudo de coorte pós-hospitalização. Rev. Bras. Geriatr. Gerontol. 2013; 16(3):579-589..

A study conducted in Italy using the same instruments also found an association between nutritional risk/malnourishment andvulnerability²⁸28 Luciani A, Ascione G, Bertuzzi C, Marussi D, Codecà C, Di Maria G, Caldiera SE, Floriani I, Zonato S, Ferrari D, Foa P. Detecting disabilities in older patients with cancer: comparison between Comprehensive Geriatric Assessment and Vulnerable Elders Survey-13. J Clinic Oncol 2010; 28(12):2046-2050.. Nutrient deficiency is a significant problem among older people, since physiological changes influence food intake and nutrient absorption, increasing the risk of malnutrition³3 Brasil. Ministério da Saúde (MS). Envelhecimento e saúde da pessoa idosa. Brasília: MS; 2006..

Bivariate analysis also revealed an association between polypharmacy and vulnerability. A study using the same definition of polypharmacy as the present study found an association between multiple medication use and vulnerability assessed using the VES-13²⁸28 Luciani A, Ascione G, Bertuzzi C, Marussi D, Codecà C, Di Maria G, Caldiera SE, Floriani I, Zonato S, Ferrari D, Foa P. Detecting disabilities in older patients with cancer: comparison between Comprehensive Geriatric Assessment and Vulnerable Elders Survey-13. J Clinic Oncol 2010; 28(12):2046-2050.. A similar association was reported by a study conducted in Portugal with 206 older persons with gastrointestinal cancer using the VES-13and a different definition of polypharmacy⁴¹41 Carneiro F, Sousa N, Azevedo LF, Saliba D. Vulnerability in elderly patients with gastrointestinal cancer - translation, cultural adaptation and validation of the European Portuguese version of the Vulnerable Elders Survey (VES-13). BMC Cancer 2015; 15:723.. Likewise, the study in Italy mentioned above highlighted a correlation between vulnerability and multiple drug use²⁸28 Luciani A, Ascione G, Bertuzzi C, Marussi D, Codecà C, Di Maria G, Caldiera SE, Floriani I, Zonato S, Ferrari D, Foa P. Detecting disabilities in older patients with cancer: comparison between Comprehensive Geriatric Assessment and Vulnerable Elders Survey-13. J Clinic Oncol 2010; 28(12):2046-2050.. The use of multiple medications by older persons can lead to an increased occurrence of adverse effects. In this respect, the possibility cannot be excluded that many common comorbidities among older persons are caused or potentiated by the action of certain medications or different combinations of drugs⁴²42 Cabrera M. Polifarmácia e Adequação do Uso de Medicamentos. In: Freitas EV, Py L, editoras. Tratado de Geriatria e Gerontologia. 3ª ed. Rio de Janeiro: Guanabara Koogan; 2011. p. 1490-1498.. Thus, the association between polypharmacy and vulnerability may be explained by the link between adverse effects caused by multiple medication use and vulnerability.

This study has some limitations. First, cross-sectional studies analyze exposure variables and outcome simultaneously, meaning they are limited in their ability to determine the cause-and-effect relationship between variables. Second, the information collected was self-reported, which could have led to an underestimation of the prevalence of conditions that are commonly underdiagnosed. In this respect, due care was taken to check the data with family members and/carers and with interviewee training and the standardization of data collection. Thirdly, it is possible that recall bias may have occurred; however, its overall effect was minimized by excluding older persons with cognitive impairment and information checking, as mentioned above. Finally, since the study was conducted with ESF service users, caution should be taken when extrapolating the results to the general elderly population of Várzea Grande.

Positive aspects of the study include the fact that it is one of the first studies in the country to assess the prevalence of vulnerability and associated factors among community-dwelling older peopleusing primary care services. The importance of identifying vulnerability in older people to prevent adverse health outcomes is demonstrated by the findings of the VES-13 study, conducted with community-dwelling older people (aged 65 years and older) who were Medicare beneficiaries⁵5 Saliba D, Elliott M, Rubenstein LZ, Solomon DH, Young RT, Kamberg CJ, Roth C, MacLean CH, Shekelle PG, Sloss EM, Wenger NS. The Vulnerable Elders Survey: a tool for identifying vulnerable older people in the community. J Am Geriatr Soc 2001; 49(12):1691-1699.. The study found that respondents identified as vulnerable had 4.2 times the risk of functional decline or death over a two- year period, compared to those who were not vulnerable.

Studies using the VES-13 with hospitalized older people and cancer patients in the United States reported vulnerability prevalence rates of between 52 and 58%²⁹29 Bell SP, Schnelle J, Nwosu SK, Schildcrout J, Goggins K, Cawthon C, Mixon AS, Vasilevskis EE, Kripalani S. Development of a multivariable model to predict vulnerability in older American patients hospitalised with cardiovascular disease. BMJ 2015; 5(8):1-8.^,4343 Arora VM, Johnson M, Olson J, Podrazik PM, Levine S, DuBeau CE, Sachs GA, Meltzer DO. Using assessing care of vulnerable elders quality indicators to measure quality of hospital care for vulnerable elders. J Am Geriatr Soc 2007; 55(11):1705-1711.^,4444 Arora VM, Plein C, Chen S, Siddique J, Sachs GA, Meltzer DO. Relationship between quality of care and functional decline in hospitalized vulnerable elders. Med Care 2009; 47(8):895-901.. Follow-up studies have demonstrated that the VES-13 has good predictive ability²⁸28 Luciani A, Ascione G, Bertuzzi C, Marussi D, Codecà C, Di Maria G, Caldiera SE, Floriani I, Zonato S, Ferrari D, Foa P. Detecting disabilities in older patients with cancer: comparison between Comprehensive Geriatric Assessment and Vulnerable Elders Survey-13. J Clinic Oncol 2010; 28(12):2046-2050.^,4545 Min L, Yoon W, Mariano J, Neil S, Wenger, Elliott MN, Kamberg C, Saliba D. The Vulnerable Elders-13 Survey Predicts 5-year Functional Decline and Mortality Outcomes Among Older Ambulatory Care Patients. J Am Geriatr Soc 2009; 57(11):2070-2076.. An analysis with patients undergoing treatment for cancer conducted in the United States found a vulnerability prevalence rate of around 50%²⁴24 Mohile SG, Bylow K, Dale W, Dignam J, Martin K, Petrylac DP, Stadler WM, Rodin M. A pilot study of the Vulnerable Elders Survey-13 compared with the Comprehensive Geriatric Assessment for identifying disability in older patients with prostate cancer who receive androgen ablation. Cancer 2007; 109(4):802-810.^,2828 Luciani A, Ascione G, Bertuzzi C, Marussi D, Codecà C, Di Maria G, Caldiera SE, Floriani I, Zonato S, Ferrari D, Foa P. Detecting disabilities in older patients with cancer: comparison between Comprehensive Geriatric Assessment and Vulnerable Elders Survey-13. J Clinic Oncol 2010; 28(12):2046-2050., while a study undertaken in Rio de Janeiro and Campo Grande with older persons with prostate cancer reported a similar prevalence rate to that found by the present study³¹31 Luz LL. Avaliação multidimensional da saúde de idosos com câncer de próstata e o 'The Vulnerable Elders Survey 13' (VES-13) como instrumento de triagem em oncogeriatria [tese]. Rio de Janeiro: Escola Nacional de Saúde Pública Sérgio Arouca; 2015.. However, since these studies were carried out with specific population groups, the comparability of their respective results is limited.

Conclusion

The prevalence of vulnerability found by the present study was high when compared to other studies with community-dwelling older people. The presence of dependence in IADLs and depressive symptoms and being aged80 years and over were associated with vulnerability. It is therefore important that older persons who are screened and identified as vulnerable are followed up more effectively by primary healthcare professionals. Our findings suggest that new approaches to healthcare for community-dwelling older persons that go beyond existing policies and programs should be adopted.

The early detection of vulnerability can help meet the primary health needs of older persons by allowing care professionals to elaborate care plans that prevent functional decline and early death.

The majority of studies involving older people are conducted in long-term care institutions, where sociodemographic profiles are different and morbidity rates tend to be higher than among the general population. Further longitudinal studies focusing on multifunctional geriatric assessment should be conducted in primary care settings to inform the development of effective health promotion and protection strategies tailored to this population group.

Agradecimentos

Pesquisa financiada pela Fundação de Amparo à Pesquisa do Estado de Mato Grosso (Fapemat).

References

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History