ABSTRACT

OBJECTIVE

To determine the demographic and health factors related to the frailty syndrome in older adults.

METHODS

This is a longitudinal quantitative study carried out with 262 older adults aged 65 years and older, of both sexes, living at home. Data collection was carried out in Period 1 between October 2007 and February 2008, and in Period 2 between July and December 2013. For data collection, we used the sociodemographic profile instrument, the Edmonton Frail Scale, the Mini-Mental State Examination, the number of falls in the last 12 months, the number of self-reported diseases and used drugs, the Functional Independence Measure, and the Lawton and Brody Scale. We used descriptive statistics for data analysis, in the comparison of the means between periods, the nonparametric Wilcoxon test, and the method of Generalized Estimating Equations, which is considered an extension of the Generalized Linear Models with p ≤ 0.05.

RESULTS

Of the 515 participants, 262 completed the follow-up, with a predominance of females, older individuals, and those who had no partner; there was an increase in frail older adults. In the Generalized Estimating Equations analysis, frailty score was related to sociodemographic (increase in age, no partner, and low education level) and health variables (more diseases, drugs, falls, and decrease in functional capacity). There was an association between the variables of age (older), marital status (no partner), and loss of functional capacity.

CONCLUSIONS

Frailty syndrome was associated with increasing age, having no partner, and decreased functional capacity over time, and investments are required to prevent this syndrome and promote quality in aging.

Aged; Frail Elderly; Risk Factors; Socioeconomic Factors; Aging

INTRODUCTION

The frailty syndrome is the decrease of the homeostatic reserves of the organism and resistance to stressors. It results in a decline of the physiological system¹1. Fried LP, Tangen CM, Walston J, Newman AB, Hirsch C, Gottdiener J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001;56(3):M146-56. https://doi.org/10.1093/gerona/56.3.M146
https://doi.org/10.1093/gerona/56.3.M146... , based on the triad of the different changes related to the aging process, consisting of sarcopenia, immunological dysfunction, and neuroendocrine dysregulation²2. Ferrucci L, Guralnik JM, Studenski S, Fried LP. Cutler GB Jr, Walston JD, et al. Designing randomized, controlled trials aimed at preventing or delaying functional decline and disability in frail, older persons: a consensus report. J Am Geriatr Soc. 2004;52(4):625-34. https://doi.org/10.1111/j.1532-5415.2004.52174.x
https://doi.org/10.1111/j.1532-5415.2004... .

The multidimensional construct with a holistic approach is established or altered by biological, psychological, and social factors. It emphasizes the existing complex etiology, which is understood as a non-optimal condition of multifactorial and dynamic nature related to history or life trajectory³3. Rockwood K, Mitnitski A. Frailty in relation to the accumulation of deficits. J Gerontol A Biol Sci Med Sci. 2007;62(7):722-7. https://doi.org/10.1093/gerona/62.7.722
https://doi.org/10.1093/gerona/62.7.722... .

A group of six European and American societies has defined frailty as: “a medical syndrome with multiple causes and contributors that is characterized by diminished strength, endurance, and reduced physiologic function that increases an individual’s vulnerability for developing increased dependency and/or death”⁴4. Morley JE, Vellas B, Kan GA, Anker SD, Bauer JM, Bernabei R, et al. Frailty consensus: a call to action. J Am Med Dir Assoc. 2013;14(6):392-7. https://doi.org/10.1016/j.jamda.2013.03.022
https://doi.org/10.1016/j.jamda.2013.03.... (p.4).

Frailty is related to demographic factors, such as being female, increasing age⁵5. Song X, Mitnitski A, Rockwood K. Prevalence and 10-year outcomes of frailty in older adults in relation to deficit accumulation. J Am Geriatr Soc. 2010;58(4):681-7. https://doi.org/10.1111/j.1532-5415.2010.02764.x
https://doi.org/10.1111/j.1532-5415.2010... , and the presence of adverse health events, such as decreased cognitive status⁶6. Kang JY, Kim CH, Sung EJ, Shin HC, Shin WJ, Jung KH. The association between frailty and cognition in elderly women. Korean J Fam Med. 2016;37(3):164-70. https://doi.org/10.4082/kjfm.2016.37.3.164
https://doi.org/10.4082/kjfm.2016.37.3.1... , polypharmacy⁷7. Afilalo J, Karunananthan S, Eisenberg MJ, Alexander KP, Bergman H. Role of frailty in patients with cardiovascular disease. Am J Cardiol. 2009;103(11):1616-21. https://doi.org/10.1016/j.amjcard.2009.01.375
https://doi.org/10.1016/j.amjcard.2009.0... , sarcopenia⁸8. Cesari M, Landi F, Vellas B, Bernabei R, Marzetti E. Sarcopenia and physical frailty: two sides of the same coin. Front Aging Neurosci. 2014;6:192. https://doi.org/10.3389/fnagi.2014.00192
https://doi.org/10.3389/fnagi.2014.00192... , falls⁹9. Kojima G, Kendrick D, Skelton DA, Morris RW, Gawler S, Iliffe S. Frailty predicts short-term incidence of future falls among British community-dwelling older people: a prospective cohort study nested within a randomised controlled trial. BMC Geriatr. 2015;15:155. https://doi.org/10.1186/s12877-015-0152-7
https://doi.org/10.1186/s12877-015-0152-... , institutionalization, hospitalization¹⁰10. Fabrício-Wehbe SCC, Rodrigues RAP, Haas VJ, Fhon JRS, Diniz MA. Association of frailty in hospitalized and institutionalized elderly in the community-dwelling. Rev Bras Enferm. 2016;69(4):691-6. https://doi.org/10.1590/0034-7167.2016690411i
https://doi.org/10.1590/0034-7167.201669... , and death¹¹11. Theou O, Rockwood MR, Mitnitski A, Rockwood K. Disability and co-morbidity in relation to frailty: how much do they overlap? Arch Gerontol Geriatr. 2012;55(2):e1-8. https://doi.org/10.1016/j.archger.2012.03.001
https://doi.org/10.1016/j.archger.2012.0... .

The changes that occur in an individual during the aging process encompass physical, psychic, and social aspects that make him or her more vulnerable. The increase in life expectancy has become a victory for society because of improvements in health services and accessibility to them. Nurses need constant training in the care for the older population to respond to the demands of frail older adults, which can go unnoticed and shorten their life expectancy. The evaluation of the older adult in primary care is also up to the nurse; thus, new possibilities to evaluate this population are available in the literature, which enables the planning of care for the older adult at home. The objective of this study was to determine the demographic and health factors related to the frailty syndrome in older adults.

METHODS

This is a longitudinal study carried out in the city of Ribeirão Preto, State of São Paulo, Brazil. Data collection was carried out in Period 1 (P1), the first collection, between October 2007 and February 2008, and in Period 2 (P2), the second collection, between July and December 2013.

We used the probabilistic method and conglomerate in two stages for the sampling process. In the second stage, we made home visits to ensure a self-weighting sample. We randomly selected the street and block of the tracts, and we needed to visit at least 110 households in each tract. We randomly selected 993 older adults; but the final sample was 515 (51%) participants.

Inclusion criteria in P1 were: being an older adult aged ≥ 65 years, both sexes, being able to communicate verbally, and living at home. For P2, they were: having participated in P1 and being able to communicate.

Data collection in P1 followed the counterclockwise direction of the randomly selected blocks, and we eliminated from the sample the older adult who was not at home after three visits. For P2, we contacted the older adult or family member by telephone to arrange a home visit or the visit to the address in order to schedule the interview according to the availability of the older adult.

The sample consisted of 515 older adults in P1 and 262 older adults in P2. Among the losses, in the five years, 24.7% of them died, 16.1% refused to participate in the research, 1.6% was institutionalized, and 6.8% moved to other cities.

We used the following instruments:

• Demographic profile, with information on sex (male and female), age (in years), marital status, and education level (in years of formal study);

• Self-reported diseases and number of drugs, from the self-report of the participant and the checking of drugs and medical prescription;

• Edmonton Frail Scale (EFS), used to evaluate the frailty syndrome¹²12. Rolfson DB, Majumdar SR, Tsuyuki RT, Tahir A, Rockwood K. Validity and reliability of the Edmonton Frail Scale. Age Ageing. 2006;35(5):526-9. https://doi.org/10.1093/ageing/afl041
  https://doi.org/10.1093/ageing/afl041... and validated and reproduced in Brazilian Portuguese¹³13. Fabricio-Wehbe SCC, Schiaveto FV, Vendrusculo TRP, Haas VJ, Dantas RAS, Rodrigues RAP. Cross-cultural adaptation and validity of the Edmonton Frail Scale – EFS in a Brazilian elderly simple. Rev Lat Am Enfermagem, 2009;17(6):1043-9. https://doi.org/10.1590/S0104-11692009000600018
  https://doi.org/10.1590/S0104-1169200900... ^,1414. Fabricio-Wehbe SCC, Cruz IR, Haas VJ, Diniz MA, Dantas RAS, Rodrigues RAP. Reproducibility of the Brazilian version of the Edmonton Frail Scale for elderly living in the community. Rev Lat Am Enfermagem. 2013;21(6):1330-6. https://doi.org/10.1590/0104-1169.2933.2371
  https://doi.org/10.1590/0104-1169.2933.2... with nine domains represented in eleven items. According to the cut-off point, the older adult can be categorized as: not frail (0–4), apparently vulnerable (5–6), mild frailty (7–8), moderate frailty (9–10), and severe frailty (11 or more);

• Instrument for falls, number of falls in the last 12 months;

• Mini-Mental State Examination (MMSE), used to evaluate the cognitive function, translated, validated, and revised for Brazilian Portuguese¹⁵15. Brucki SMD, Nitrini R, Caramelli P, Bertolucci PHF, Okamoto IH. Sugestões para o uso do mini-exame do estado mental no Brasil. Arq Neuro Psiquiatr. 2003;61(3B):777-81. https://doi.org/10.1590/S0004-282X2003000500014
  https://doi.org/10.1590/S0004-282X200300... , with questions grouped into seven categories and evaluation of different cognitive functions. Score ranges from zero to 30 points;

• Functional Independence Measure (FIM), developed in order to measure the degree of care need by the disabled patient to perform motor and cognitive tasks and reproduced¹⁶16. Riberto M, Miyazaki MH, Jorge Filho D, Sakamoto H, Battistella LR. Reprodutibilidade da versão brasileira da Medida de Independência Funcional. Ata Fisiatr. 2001;8(1):45-52. https://doi.org/10.5935/0104-7795.20010002
  https://doi.org/10.5935/0104-7795.200100... and validated¹⁷17. Riberto M, Miyazaki MH, Jucá SSH, Sakamoto H, Pinto PPN, Battistella LR. Validação versão brasileira da Medida de Independência Funcional. Acta Fisiatr. 2004;11(2):72-6. https://doi.org/10.5935/0104-7795.20040003
  https://doi.org/10.5935/0104-7795.200400... for Portuguese. It has a score ranging from one (complete dependence) to seven (complete independence); the total score varies from 18 to 126 points and the higher scores refer to greater independence;

• Lawton and Brody scale, validated for Portuguese¹⁸18. Santos RL, Virtuoso Jr JS. Confiabilidade da versão brasileira da Escala de Atividades Instrumentais da Vida Diária. RBPS. 2008;21(4):290-6. https://doi.org/10.5020/575
  https://doi.org/10.5020/575... , it encompasses complex social activities. It evaluates the ability of the older adult to live in the community and measures the Instrumental Activities of Daily Living (IADL). The score varies from seven (highest level of dependency) to twenty-one points (complete independence), categorizing the older adult in total dependence (7 points), partial dependence (8–20 points), and independence (21 points).

We used descriptive statistics for quantitative data, as well as the measure of central tendency (mean and median) and dispersion (standard deviation); we used frequency and percentages for the categorical variables. We used the non-parametric Wilcoxon test to compare the means between P1 and P2.

In order to analyze the relationship between frailty and the sociodemographic (sex, age, education level, and marital status) and health variables (cognitive status, functional capacity, falls, and number of morbidities and drugs), we used the Generalized Estimating Equations (GEE). This method is considered an extension of the Generalized Linear Models (GLM), and it takes advantage of the assumptions of the existence of a mean link function with covariates and the response variable not needing to belong to the exponential family of distributions; it adds a correlation structure among repeated measures.

The dependent variable of the analysis was the frailty score, with integer values from zero to seventeen, following a Poisson distribution. The independent variables were age (in years), sex (male and female), marital status (with partner and without partner), education level (in years), falls (yes and no), total number of diseases, total number of drugs, cognitive status (with or without deficit), and scores of the FIM and IADL scales.

We calculated relative increase for the resulting final model based on the mean regression parameters: RI (β) = (EXP(β) – 1) × 100%, where β is the parameter vector of the adjusted model. For all statistical tests, significance was p ≤ 0.05.

The study was approved by the Research Ethics Committee of the Escola de Enfermagem de Ribeirão Preto of Universidade de São Paulo (Protocols 0851/2007 and 1392/2011) and the participants signed the informed consent.

RESULTS

In the evaluation of frailty of the 262 older adults of the cohort, in P1, 17.6% of the participants were considered frail, 22.9% vulnerable, and 59.5% not frail. In P2, 50.4% were frail, 21.0% vulnerable, and 28.6% not frail. Those aged 80 years or more, females, those without a partner, and those with a lower mean education level were predominant compared to the other categories (Table 1). Mean frailty increased from 4.2 (standard deviation [SD] = 2.6) in P1 to 6.5 (SD = 3.1) in P2 with p < 0.001.

In the GEE analysis, the total frailty score was related to some sociodemographic variables such as age: for each additional year, we estimated a mean increase of 0.8% in the frailty score. The older adults who did not have a partner had a mean frailty score of 10.4%, higher than those with a partner. On the other hand, we estimated a decrease of 1.2% in the frailty score for each additional year of education. There was an increase in mean frailty score of 1.7% for each drug used by the older adult. Mean frailty score increased 14.1% for each fall that the older adult suffered and 3.2% for each disease present (Table 2).

In the adjustment obtained by the GEE in the dispersion analysis, the relative increase in mean frailty was 0.5% at each year of age and 8.4% for those who did not have a partner. There was a relative decrease in the mean of 0.9% for each year of study.

Frailty had a relative increase in the mean of 3.3% for each additional disease, as well as 11.1% for the older adult who suffered a fall. In the final analysis, we verified a decrease of 0.011 points in the dispersion in the score of the frailty scale for each year of age and a decrease of 0.172 points in the dispersion for those who did not have a partner. There was a decrease of 0.0044 points in the dispersion of the frailty score for each additional point of the FIM. The opposite occurred in the evaluation using the Lawton and Brody Scale, with an increase of 0.0491 points in the dispersion for each IADL point (Table 3).

DISCUSSION

Most participants (P2) were considered frail, with a predominance of females, older individuals (80 years or more), those without a partner, and those with low education level. We can observe differences in the means in the evaluation of older adults in both periods and the relation between frailty and age (older), marital status (no partner), and decreased functional capacity over time.

Mean frailty and the frailty category increased from P1 to P2. This finding is consistent with the study of Hyde et al.¹⁹19. Hyde Z; Flicker L, Smith K, Atkinson D, Fenner S, Skeaf l, et al. Prevalence and incidence of frailty in aboriginal Australians, and associations with mortality and disability. Maturitas. 2016;87(1):89-94. https://doi.org/10.1016/j.maturitas.2016.02.013
https://doi.org/10.1016/j.maturitas.2016... These researchers, when estimating the prevalence and incidence of frailty in older Australians, have observed that the prevalence of frailty increased from 65.3% to 67.6% and incidence reached 51.4% in 10 years¹⁹19. Hyde Z; Flicker L, Smith K, Atkinson D, Fenner S, Skeaf l, et al. Prevalence and incidence of frailty in aboriginal Australians, and associations with mortality and disability. Maturitas. 2016;87(1):89-94. https://doi.org/10.1016/j.maturitas.2016.02.013
https://doi.org/10.1016/j.maturitas.2016... .

The frailty syndrome causes an accelerated decline in the physiological reserve, and homeostatic mechanisms begin to fail²2. Ferrucci L, Guralnik JM, Studenski S, Fried LP. Cutler GB Jr, Walston JD, et al. Designing randomized, controlled trials aimed at preventing or delaying functional decline and disability in frail, older persons: a consensus report. J Am Geriatr Soc. 2004;52(4):625-34. https://doi.org/10.1111/j.1532-5415.2004.52174.x
https://doi.org/10.1111/j.1532-5415.2004...

3. Rockwood K, Mitnitski A. Frailty in relation to the accumulation of deficits. J Gerontol A Biol Sci Med Sci. 2007;62(7):722-7. https://doi.org/10.1093/gerona/62.7.722
https://doi.org/10.1093/gerona/62.7.722...

4. Morley JE, Vellas B, Kan GA, Anker SD, Bauer JM, Bernabei R, et al. Frailty consensus: a call to action. J Am Med Dir Assoc. 2013;14(6):392-7. https://doi.org/10.1016/j.jamda.2013.03.022
https://doi.org/10.1016/j.jamda.2013.03....

5. Song X, Mitnitski A, Rockwood K. Prevalence and 10-year outcomes of frailty in older adults in relation to deficit accumulation. J Am Geriatr Soc. 2010;58(4):681-7. https://doi.org/10.1111/j.1532-5415.2010.02764.x
https://doi.org/10.1111/j.1532-5415.2010...

6. Kang JY, Kim CH, Sung EJ, Shin HC, Shin WJ, Jung KH. The association between frailty and cognition in elderly women. Korean J Fam Med. 2016;37(3):164-70. https://doi.org/10.4082/kjfm.2016.37.3.164
https://doi.org/10.4082/kjfm.2016.37.3.1...

7. Afilalo J, Karunananthan S, Eisenberg MJ, Alexander KP, Bergman H. Role of frailty in patients with cardiovascular disease. Am J Cardiol. 2009;103(11):1616-21. https://doi.org/10.1016/j.amjcard.2009.01.375
https://doi.org/10.1016/j.amjcard.2009.0...

8. Cesari M, Landi F, Vellas B, Bernabei R, Marzetti E. Sarcopenia and physical frailty: two sides of the same coin. Front Aging Neurosci. 2014;6:192. https://doi.org/10.3389/fnagi.2014.00192
https://doi.org/10.3389/fnagi.2014.00192...

9. Kojima G, Kendrick D, Skelton DA, Morris RW, Gawler S, Iliffe S. Frailty predicts short-term incidence of future falls among British community-dwelling older people: a prospective cohort study nested within a randomised controlled trial. BMC Geriatr. 2015;15:155. https://doi.org/10.1186/s12877-015-0152-7
https://doi.org/10.1186/s12877-015-0152-...

10. Fabrício-Wehbe SCC, Rodrigues RAP, Haas VJ, Fhon JRS, Diniz MA. Association of frailty in hospitalized and institutionalized elderly in the community-dwelling. Rev Bras Enferm. 2016;69(4):691-6. https://doi.org/10.1590/0034-7167.2016690411i
https://doi.org/10.1590/0034-7167.201669...

11. Theou O, Rockwood MR, Mitnitski A, Rockwood K. Disability and co-morbidity in relation to frailty: how much do they overlap? Arch Gerontol Geriatr. 2012;55(2):e1-8. https://doi.org/10.1016/j.archger.2012.03.001
https://doi.org/10.1016/j.archger.2012.0...

12. Rolfson DB, Majumdar SR, Tsuyuki RT, Tahir A, Rockwood K. Validity and reliability of the Edmonton Frail Scale. Age Ageing. 2006;35(5):526-9. https://doi.org/10.1093/ageing/afl041
https://doi.org/10.1093/ageing/afl041...

13. Fabricio-Wehbe SCC, Schiaveto FV, Vendrusculo TRP, Haas VJ, Dantas RAS, Rodrigues RAP. Cross-cultural adaptation and validity of the Edmonton Frail Scale – EFS in a Brazilian elderly simple. Rev Lat Am Enfermagem, 2009;17(6):1043-9. https://doi.org/10.1590/S0104-11692009000600018
https://doi.org/10.1590/S0104-1169200900...

14. Fabricio-Wehbe SCC, Cruz IR, Haas VJ, Diniz MA, Dantas RAS, Rodrigues RAP. Reproducibility of the Brazilian version of the Edmonton Frail Scale for elderly living in the community. Rev Lat Am Enfermagem. 2013;21(6):1330-6. https://doi.org/10.1590/0104-1169.2933.2371
https://doi.org/10.1590/0104-1169.2933.2...

15. Brucki SMD, Nitrini R, Caramelli P, Bertolucci PHF, Okamoto IH. Sugestões para o uso do mini-exame do estado mental no Brasil. Arq Neuro Psiquiatr. 2003;61(3B):777-81. https://doi.org/10.1590/S0004-282X2003000500014
https://doi.org/10.1590/S0004-282X200300...

16. Riberto M, Miyazaki MH, Jorge Filho D, Sakamoto H, Battistella LR. Reprodutibilidade da versão brasileira da Medida de Independência Funcional. Ata Fisiatr. 2001;8(1):45-52. https://doi.org/10.5935/0104-7795.20010002
https://doi.org/10.5935/0104-7795.200100...

17. Riberto M, Miyazaki MH, Jucá SSH, Sakamoto H, Pinto PPN, Battistella LR. Validação versão brasileira da Medida de Independência Funcional. Acta Fisiatr. 2004;11(2):72-6. https://doi.org/10.5935/0104-7795.20040003
https://doi.org/10.5935/0104-7795.200400...

18. Santos RL, Virtuoso Jr JS. Confiabilidade da versão brasileira da Escala de Atividades Instrumentais da Vida Diária. RBPS. 2008;21(4):290-6. https://doi.org/10.5020/575
https://doi.org/10.5020/575...

19. Hyde Z; Flicker L, Smith K, Atkinson D, Fenner S, Skeaf l, et al. Prevalence and incidence of frailty in aboriginal Australians, and associations with mortality and disability. Maturitas. 2016;87(1):89-94. https://doi.org/10.1016/j.maturitas.2016.02.013
https://doi.org/10.1016/j.maturitas.2016...

20. Bandeen-Roche K, Seplaki C, Huang J, Buta B, Kalyani RR, Varadhan R, et al. Frailty in older adults: a nationally representative profile in the United States. J Gerontol A Biol Sci Med Sci. 2015:70(11):1427-34. https://doi.org/10.1093/gerona/glv133
https://doi.org/10.1093/gerona/glv133... ^-2121. Eeles EM, White SV, O’Mahony SM, Bayer AJ, Hubbard RE. The impact of frailty and delirium on mortality in older inpatients. Age Ageing. 2012;41(3):412-6. https://doi.org/10.1093/ageing/afs021
https://doi.org/10.1093/ageing/afs021... from the cumulative decline in the physiological system derived from mechanical complexes. There is consequent an erosion of the homeostatic reserve and vulnerability to disproportionate changes in health status after relatively minor stress events²²22. Clegg A, Young J, IIiffe S, Rekkert MO, Rockwood K. Frailty in elderly people. Lancet. 2013;381(9868):752-62. https://doi.org/10.1016/S0140-6736(12)62167-9
https://doi.org/10.1016/S0140-6736(12)62... . There is a continuous loss of strength and aerobic resistance, which causes a decrease in functional independence and makes the older adult frail²³23. Walston JD. Sarcopenia in older adults. Curr Opin Rheumatol. 2012;24(6):623-7. https://doi.org/10.1097/BOR.0b013e328358d59b
https://doi.org/10.1097/BOR.0b013e328358... . This loss is related to increased age²⁴24. Bartley MM, Geda YE, Christianson TJH, Pankratz VS, Roberts RO, Petersen RC. Frailty and mortality outcomes in cognitively normal older people: sex differences in a population-based study. J Am Geriatr Soc. 2016;64(1):132-7. https://doi.org/10.1111/jgs.13821
https://doi.org/10.1111/jgs.13821... , females, and low education level²⁵25. Liotta G, O’Caoimh R, Gilardi F, Proietti MG, Rocco G, Alvaro R, et al. Assesment of frailty in community-dwelling older adults residents in the Lazio region (Italy): a model to plan regional community-based services. Arch Gerontol Geriatr. 2017;68:1-7. https://doi.org/10.1016/j.archger.2016.08.004
https://doi.org/10.1016/j.archger.2016.0... .

In the dispersion analysis model, greater frailty was related to increased age. On the other hand, a study with 14,424 older adults in a two-year follow-up has observed an increase in frailty with increasing age, especially among those aged 75 years or more²⁶26. Etman A, Burdorf A, Van der Cammen TJ, Mackenbach JP, Van Lenthe FJ. Socio-demographic determinants of worsening in frailty among community-dwelling older people in 11 European countries. J Epidemiol Community Health. 2012;66(12):1116-21. https://doi.org/10.1136/jech-2011-200027
https://doi.org/10.1136/jech-2011-200027... .

The relation between age and frailty is due to the oxidative stress modulated by endogenous and exogenous agents influencing cellular oxygen production. This leads to DNA damage and causes changes in the cell with dysregulation in the inflammatory process, apoptosis, necrosis, and proliferation, which results in disadvantageous conditions, such as sarcopenia and fragility⁸8. Cesari M, Landi F, Vellas B, Bernabei R, Marzetti E. Sarcopenia and physical frailty: two sides of the same coin. Front Aging Neurosci. 2014;6:192. https://doi.org/10.3389/fnagi.2014.00192
https://doi.org/10.3389/fnagi.2014.00192...

9. Kojima G, Kendrick D, Skelton DA, Morris RW, Gawler S, Iliffe S. Frailty predicts short-term incidence of future falls among British community-dwelling older people: a prospective cohort study nested within a randomised controlled trial. BMC Geriatr. 2015;15:155. https://doi.org/10.1186/s12877-015-0152-7
https://doi.org/10.1186/s12877-015-0152-...

10. Fabrício-Wehbe SCC, Rodrigues RAP, Haas VJ, Fhon JRS, Diniz MA. Association of frailty in hospitalized and institutionalized elderly in the community-dwelling. Rev Bras Enferm. 2016;69(4):691-6. https://doi.org/10.1590/0034-7167.2016690411i
https://doi.org/10.1590/0034-7167.201669...

11. Theou O, Rockwood MR, Mitnitski A, Rockwood K. Disability and co-morbidity in relation to frailty: how much do they overlap? Arch Gerontol Geriatr. 2012;55(2):e1-8. https://doi.org/10.1016/j.archger.2012.03.001
https://doi.org/10.1016/j.archger.2012.0...

12. Rolfson DB, Majumdar SR, Tsuyuki RT, Tahir A, Rockwood K. Validity and reliability of the Edmonton Frail Scale. Age Ageing. 2006;35(5):526-9. https://doi.org/10.1093/ageing/afl041
https://doi.org/10.1093/ageing/afl041...

13. Fabricio-Wehbe SCC, Schiaveto FV, Vendrusculo TRP, Haas VJ, Dantas RAS, Rodrigues RAP. Cross-cultural adaptation and validity of the Edmonton Frail Scale – EFS in a Brazilian elderly simple. Rev Lat Am Enfermagem, 2009;17(6):1043-9. https://doi.org/10.1590/S0104-11692009000600018
https://doi.org/10.1590/S0104-1169200900...

14. Fabricio-Wehbe SCC, Cruz IR, Haas VJ, Diniz MA, Dantas RAS, Rodrigues RAP. Reproducibility of the Brazilian version of the Edmonton Frail Scale for elderly living in the community. Rev Lat Am Enfermagem. 2013;21(6):1330-6. https://doi.org/10.1590/0104-1169.2933.2371
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19. Hyde Z; Flicker L, Smith K, Atkinson D, Fenner S, Skeaf l, et al. Prevalence and incidence of frailty in aboriginal Australians, and associations with mortality and disability. Maturitas. 2016;87(1):89-94. https://doi.org/10.1016/j.maturitas.2016.02.013
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20. Bandeen-Roche K, Seplaki C, Huang J, Buta B, Kalyani RR, Varadhan R, et al. Frailty in older adults: a nationally representative profile in the United States. J Gerontol A Biol Sci Med Sci. 2015:70(11):1427-34. https://doi.org/10.1093/gerona/glv133
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21. Eeles EM, White SV, O’Mahony SM, Bayer AJ, Hubbard RE. The impact of frailty and delirium on mortality in older inpatients. Age Ageing. 2012;41(3):412-6. https://doi.org/10.1093/ageing/afs021
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22. Clegg A, Young J, IIiffe S, Rekkert MO, Rockwood K. Frailty in elderly people. Lancet. 2013;381(9868):752-62. https://doi.org/10.1016/S0140-6736(12)62167-9
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25. Liotta G, O’Caoimh R, Gilardi F, Proietti MG, Rocco G, Alvaro R, et al. Assesment of frailty in community-dwelling older adults residents in the Lazio region (Italy): a model to plan regional community-based services. Arch Gerontol Geriatr. 2017;68:1-7. https://doi.org/10.1016/j.archger.2016.08.004
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Frailty was related to older adults who did not have a partner. Other studies have also presented this information²⁸28. Runzer-Colmenares FM, Samper-Ternent R, Al Snih S, Ottenbacher KJ, Parodi JF, Wong R. Prevalence and factors associated with frailty among Peruvian older adults. Arch Gerontol Geriatr. 2014;58(1):69-73. https://doi.org/10.1016/j.archger.2013.07.005
https://doi.org/10.1016/j.archger.2013.0... ^,2929. Trevisan C, Veronese N, Maggi S, Baggio G, De Rui M, Bolzetta F, et al. Marital status and frailty in older people: gender differences in the Progetto Veneto Anziani Longitudinal Study. J Womens Health. 2016;25(6):630-7. https://doi.org/10.1089/jwh.2015.5592
https://doi.org/10.1089/jwh.2015.5592... ; the presence of a partner is a protective effect. The negative consequences on the physical and health status associated with the more limited family and social relationships of persons without partners increase the risk of social isolation³⁰30. Coelho T, Paúl C, Gobbens RJJ, Fernandes L. Frailty as a predictor of short-term adverse outcomes. Peer J. 2015;3:e1121. https://doi.org/10.7717/peerj.1121
https://doi.org/10.7717/peerj.1121... .

From P1 to P2, frailty was related to a decreased functional capacity in older adults. A study with 366 older adults evaluated with the Edmonton Frail Scale has shown that frailty was associated with Activities of Daily Living (ADL) (β = -0.512; p < 0.001) and IADL (β = -0.338; p < 0.01)³¹31. Perna S, Francis MD, Bologna C, Moncaglieri F, Riva A, Morazzoni P, et al. Performance of Edmonton Frail Scale on frailty assessment: its association with multi-dimensional geriatric conditions assessed with specific screening tools. BMC Geriatr. 2017;17(1):2. https://doi.org/10.1186/s12877-016-0382-3
https://doi.org/10.1186/s12877-016-0382-... . On the other hand, a systematic review has pointed out that the older adult considered frail has a high risk of disability for ADL (OR = 2.76; 95%CI 2.33–3.44; p < 0.001), as well as for IADL (OR = 3.62; 95%CI 2.32–5.64; p < 0.001)⁹9. Kojima G, Kendrick D, Skelton DA, Morris RW, Gawler S, Iliffe S. Frailty predicts short-term incidence of future falls among British community-dwelling older people: a prospective cohort study nested within a randomised controlled trial. BMC Geriatr. 2015;15:155. https://doi.org/10.1186/s12877-015-0152-7
https://doi.org/10.1186/s12877-015-0152-... .

Frailty leads to decreased strength, weakness, and worsening motor performance. These characteristics are independent of the number of diseases that the older adult has¹1. Fried LP, Tangen CM, Walston J, Newman AB, Hirsch C, Gottdiener J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001;56(3):M146-56. https://doi.org/10.1093/gerona/56.3.M146
https://doi.org/10.1093/gerona/56.3.M146... . Decreased functional capacity in frail older adults can result in high costs to health services. It is important to implement preventive actions against conditions related to different geriatric syndromes⁸8. Cesari M, Landi F, Vellas B, Bernabei R, Marzetti E. Sarcopenia and physical frailty: two sides of the same coin. Front Aging Neurosci. 2014;6:192. https://doi.org/10.3389/fnagi.2014.00192
https://doi.org/10.3389/fnagi.2014.00192... . Scientific evidence suggests that the frailty syndrome can be changed as it is a dynamic process. Interventions such as physical exercise can reverse this phenomenon in older adults, depending on the duration of the intervention. This can decrease falls and improve mobility, balance, and muscle strength³²32. Labra C, Guimaraes-Pinheiro C, Maseda A, Lorenzo T, Millán-Calenti JC. Effects of physical exercise interventions in frail older adults: a systematic review of randomized controlled trials. BMC Geriatr. 2015;15:154. https://doi.org/10.1186/s12877-015-0155-4
https://doi.org/10.1186/s12877-015-0155-... .

Two limitations should be considered. The first one refers to losses from refusals, change of address to other cities, and death over time between P1 and P2, i.e., the study was restricted to survivors. The second one refers to how the study evaluated self-reported morbidities, and not medical diagnosis or medical records, which are used in epidemiological studies. Nevertheless, the data showed that the clinical evaluation points to an evolution of the frailty of older adults and its related factors. This indicates the need for the follow-up of older adults at home by the primary health care and the need for actions to prevent this syndrome and its adverse effects.

The primary care nurse should implement the use of low cost instruments for the preservation of functional independence, as well as the reduction of adverse events such as institutionalization and early mortality.

The evolution of the frailty syndrome in older adults was associated with increasing age, no partner, and decreased functional capacity in the follow-up years. However, this does not exclude other demographic and clinical variables from influencing the presence of this syndrome in older adults.

Instruments that can be easily used by nurses in primary care enable the identification of frailty in order to promote healthy and quality aging. Nevertheless, the government needs to invest in the creation of health policies focused on the promotion and education of young and mature adults to prevent frailty.

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