ABSTRACT

OBJECTIVE

To analyze the effect of matrix support on health for older adults in primary care according to the dimensions of frailty measured with the Clinical-Functional Vulnerability Index-20 (IVCF-20).

METHODS

This is a randomized controlled community trial, developed in the Northern Minas Gerais state, Brazil, in 2018. Initially, the stratification of clinical and functional vulnerability of older adults supported by six Family Health Strategy teams occurred with the IVCF-20. Subsequently, three teams were drawn to receive matrix support for six months, and the others for control. In this intervention, face-to-face educational activities were developed for health teams. Descriptive statistics were performed, followed by bivariate analysis by Pearson’s chi-square test, to compare the variables of the IVCF-20 between the two moments (before and after the intervention), with a 5% significance level. Relative risks and respective 95% confidence intervals (95%CI) were estimated.

RESULTS

The groups were similar before intervention, and the effect of matrix actions was positive for most dimensions measured by IVCF-20 (instrumental daily living activity, cognition, mood, mobility, communication, and multiple comorbidities). At the end of the research, the percentage of frailty in the group assisted by professionals participating in matrix support was lower than that of the control group.

CONCLUSIONS

Matrix support actions, such as pedagogical attribution and horizontal care for health teams, have the potential to contribute to the articulation of models of care for older adults.

REBEC

registro BR-7b9xff

Health of the Elderly; Matrix Support; Primary Health Care; Public Health; Clinical Trial

INTRODUCTION

The fast aging of the Brazilian population defines a demographic and epidemiological profile with increasing and requiring demands on the health system, making it necessary to articulate tools for the organization, structuring, and integration of the different points of care for older adults¹1. Ministério da Saúde (BR). Diretrizes para o cuidado das pessoas idosas no SUS: proposta de modelo de atenção integral à saúde da pessoa idosa: XXX Congresso Nacional de Secretarias Municipais de Saúde [Internet]. Brasília (DF): Ministério da Saúde; 2014 [cited 2020 Dec11]. Available from: https://bvsms.saude.gov.br/bvs/publicacoes/diretrizes_cuidado_pessoa_idosa_sus.pdf
https://bvsms.saude.gov.br/bvs/publicaco... . This phenomenon requires a care model that integrally addresses older adults, in accordance with the principles and guidelines of the Brazilian Unified Health System (SUS)¹1. Ministério da Saúde (BR). Diretrizes para o cuidado das pessoas idosas no SUS: proposta de modelo de atenção integral à saúde da pessoa idosa: XXX Congresso Nacional de Secretarias Municipais de Saúde [Internet]. Brasília (DF): Ministério da Saúde; 2014 [cited 2020 Dec11]. Available from: https://bvsms.saude.gov.br/bvs/publicacoes/diretrizes_cuidado_pessoa_idosa_sus.pdf
https://bvsms.saude.gov.br/bvs/publicaco... ,²2. World Health Organization. World report on ageing and health 2015 [Internet]. Geneva: WHO; 2015 [cited 2020 Dec11]. Available from: http://www.who.int/ageing/events/world-report-2015-launch/en/
http://www.who.int/ageing/events/world-r... ,⁵5. Lino VTS, Portela MC, Camacho LAB, Rodrigues NCP, Andrade MKN, O’Dwyer G. Rastreamento de problemas de idosos na atenção primária e proposta de roteiro de triagem com uma abordagem multidimensional. Cad Saúde Pública. 2016;32(7):e00086715. https://doi.org/10.1590/0102-311X00086715.
https://doi.org/10.1590/0102-311X0008671... . The great challenge is to reshape the fragmented health system in a health care network that responds in a timely, continuous, and integrated manner, based on demographic and epidemiological aspects of the population⁶6. Veras RP, Oliveira M. Envelhecer no Brasil: a construção de um modelo de cuidado. Ciên Saúde Colet. 2018;23(6):1929-36. https://doi.org/10.1590/1413-81232018236.04722018
https://doi.org/10.1590/1413-81232018236... ,⁷7. Ministério da Saúde (BR). Orientações técnicas para a implementação de linha de cuidado para atenção integral à saúde da pessoa idosa no Sistema Único de Saúde – SUS [Internet]. Brasília (DF): Ministério da Saúde; 2018 [cited 2020 Dec11]. Available from: http://bvsms.saude.gov.br/bvs/publicacoes/linha_cuidado_atencao_pessoa_idosa.pdf
http://bvsms.saude.gov.br/bvs/publicacoe... .

The ideal structure of health care should direct the existing flow and services in care networks, acting cooperatively, interdependently, and coordinately with the Primary Health Care (PHC)¹1. Ministério da Saúde (BR). Diretrizes para o cuidado das pessoas idosas no SUS: proposta de modelo de atenção integral à saúde da pessoa idosa: XXX Congresso Nacional de Secretarias Municipais de Saúde [Internet]. Brasília (DF): Ministério da Saúde; 2014 [cited 2020 Dec11]. Available from: https://bvsms.saude.gov.br/bvs/publicacoes/diretrizes_cuidado_pessoa_idosa_sus.pdf
https://bvsms.saude.gov.br/bvs/publicaco... ,²2. World Health Organization. World report on ageing and health 2015 [Internet]. Geneva: WHO; 2015 [cited 2020 Dec11]. Available from: http://www.who.int/ageing/events/world-report-2015-launch/en/
http://www.who.int/ageing/events/world-r... ,⁷7. Ministério da Saúde (BR). Orientações técnicas para a implementação de linha de cuidado para atenção integral à saúde da pessoa idosa no Sistema Único de Saúde – SUS [Internet]. Brasília (DF): Ministério da Saúde; 2018 [cited 2020 Dec11]. Available from: http://bvsms.saude.gov.br/bvs/publicacoes/linha_cuidado_atencao_pessoa_idosa.pdf
http://bvsms.saude.gov.br/bvs/publicacoe... ,⁸8. Nunes LO, Castanheira ERL, Dias A, Zarili TFT, Sanine PR, Mendonça CS, et al. Importância do gerenciamento local para uma atenção primária à saúde nos moldes de Alma-Ata. Rev. Panam Salud Publica. 2018;42:e175. https://doi.org/10.26633/RPSP.2018.175
https://doi.org/10.26633/RPSP.2018.175... . In this context, the Family Health Strategy (FHS) – which is the priority form of PHC organization in the country – is highlighted in the operationalization of the care network for older adults¹1. Ministério da Saúde (BR). Diretrizes para o cuidado das pessoas idosas no SUS: proposta de modelo de atenção integral à saúde da pessoa idosa: XXX Congresso Nacional de Secretarias Municipais de Saúde [Internet]. Brasília (DF): Ministério da Saúde; 2014 [cited 2020 Dec11]. Available from: https://bvsms.saude.gov.br/bvs/publicacoes/diretrizes_cuidado_pessoa_idosa_sus.pdf
https://bvsms.saude.gov.br/bvs/publicaco... ,⁷7. Ministério da Saúde (BR). Orientações técnicas para a implementação de linha de cuidado para atenção integral à saúde da pessoa idosa no Sistema Único de Saúde – SUS [Internet]. Brasília (DF): Ministério da Saúde; 2018 [cited 2020 Dec11]. Available from: http://bvsms.saude.gov.br/bvs/publicacoes/linha_cuidado_atencao_pessoa_idosa.pdf
http://bvsms.saude.gov.br/bvs/publicacoe... . Comprehensive care presupposes identifying the most vulnerable, as well as monitoring the clinical-functional evolution and workflow in the organized network⁹9. Turner G, Clegg A. Best practice guidelines for the management of frailty: a British Geriatrics Society, Age UK and Royal College of General Practitioners report. Age Ageing. 2014;43(6):744-7. https://doi.org/10.1093/ageing/afu138
https://doi.org/10.1093/ageing/afu138... . This would result in fewer medical appointments and hospitalizations and better management of functionality, in addition to better cost/effectiveness in the health system¹1. Ministério da Saúde (BR). Diretrizes para o cuidado das pessoas idosas no SUS: proposta de modelo de atenção integral à saúde da pessoa idosa: XXX Congresso Nacional de Secretarias Municipais de Saúde [Internet]. Brasília (DF): Ministério da Saúde; 2014 [cited 2020 Dec11]. Available from: https://bvsms.saude.gov.br/bvs/publicacoes/diretrizes_cuidado_pessoa_idosa_sus.pdf
https://bvsms.saude.gov.br/bvs/publicaco... ,⁶6. Veras RP, Oliveira M. Envelhecer no Brasil: a construção de um modelo de cuidado. Ciên Saúde Colet. 2018;23(6):1929-36. https://doi.org/10.1590/1413-81232018236.04722018
https://doi.org/10.1590/1413-81232018236... ,⁷7. Ministério da Saúde (BR). Orientações técnicas para a implementação de linha de cuidado para atenção integral à saúde da pessoa idosa no Sistema Único de Saúde – SUS [Internet]. Brasília (DF): Ministério da Saúde; 2018 [cited 2020 Dec11]. Available from: http://bvsms.saude.gov.br/bvs/publicacoes/linha_cuidado_atencao_pessoa_idosa.pdf
http://bvsms.saude.gov.br/bvs/publicacoe... ,¹⁰10. Harrison JK, Clegg A, Conroy SP, Young J. Managing frailty as a long-term condition. Age Ageing. 2015;44(5):732-5. https://doi.org/10.1093/ageing/afv085
https://doi.org/10.1093/ageing/afv085... ,¹¹11. Inzitari M, Pérez LM, Enfedaque MB, Soto L, Díaz F, Gual N, et al. Integrated primary and geriatric care for frail older adults in the community: implementation of a complex intervention into real life. Eur J Intern Med. 2018;56:57-63. https://doi.org/10.1016/j.ejim.2018.07.022
https://doi.org/10.1016/j.ejim.2018.07.0... ,¹³13. Kojima G, Liljas AEM, Iliffe S. Frailty syndrome: implications and challenges for health care policy. Risk ManagHealthc Policy. 2019;12:23-30. https://doi.org/10.2147/RMHP.S168750
https://doi.org/10.2147/RMHP.S168750... ,¹⁴14. Gwyther H, Shaw R, Dauden EAJ, D’Avanzo B, Kurpas D, Bujnowska-Fedak M, et al. Understanding frailty: a qualitative study of European healthcare policy-makers’ approaches to frailty screening and management. BMJ Open. 2018;8(1):e018653. https://doi.org/10.1136/bmjopen-2017-018653
https://doi.org/10.1136/bmjopen-2017-018... .

There are good experiences of PHC strengthening that combine the empowerment of health teams with support for the management of health care, such as matrix support¹⁷17. Hirdes A. Apoio Matricial em saúde mental: a perspectiva dos especialistas sobre o processo de trabalho. SaúdeDebate. 2018;42(118):656-68. https://doi.org/10.1590/0103-1104201811809
https://doi.org/10.1590/0103-11042018118... ,¹⁸18. Iglesias A, Avellar LZ. Matriciamento em saúde mental: práticas e concepções trazidas por equipes de referência, matriciadores e gestores. CiênSaúde Colet. 2019;24(4):1247-54. https://doi.org/10.1590/1413-81232018244.05362017
https://doi.org/10.1590/1413-81232018244... . Matrix support (MS) in health emerged as an innovative strategy, based on the promotion of an organizational system of continuous care and educational services network within the scope of SUS¹⁷17. Hirdes A. Apoio Matricial em saúde mental: a perspectiva dos especialistas sobre o processo de trabalho. SaúdeDebate. 2018;42(118):656-68. https://doi.org/10.1590/0103-1104201811809
https://doi.org/10.1590/0103-11042018118... . The main idea of the MS is to operationalize the integrated functioning of the network by ecoparticipative and interprofessional relationship of its elements¹⁷17. Hirdes A. Apoio Matricial em saúde mental: a perspectiva dos especialistas sobre o processo de trabalho. SaúdeDebate. 2018;42(118):656-68. https://doi.org/10.1590/0103-1104201811809
https://doi.org/10.1590/0103-11042018118... ,¹⁹19. Barros JO, Gonçalves RMA, Kaltner RP, Lancman S. Matrix support strategies: the experience of two Family Health Support Centers (NASFs) in São Paulo, Brazil. Ciên Saúde Colet. 2015;20(9):2847-56. https://doi.org/10.1590/1413-81232015209.12232014
https://doi.org/10.1590/1413-81232015209...

20. Campos GWS, Domitti AC. Apoio matricial e equipe de referência: uma metodologia para gestão do trabalho interdisciplinar em saúde. Cad Saúde Pública. 2007;23(2):399-407. https://doi.org/10.1590/S0102-311X2007000200016
https://doi.org/10.1590/S0102-311X200700... -²¹21. Chiaverini DH, organizadora; GonçalvesDA, Ballester D, Tófoli LF, Chazan LF, Almeida N, Fortes S. Guia prático de matriciamento em saúde mental [Internet]. Brasília(DF): Ministério da Saúde; 2011 [cited 2020 Dec11]. Available from: http://bvsms.saude.gov.br/bvs/publicacoes/guia_pratico_matriciamento_saudemental.pdf
http://bvsms.saude.gov.br/bvs/publicacoe... . Matrix support consists of theoretical and conceptual reconstruction of interdisciplinary work methodology in health — considering the relationship between reference teams (RT) and matrix support professionals (secondary care). This support depends on the relationship between health teams, the extension of specialized care scenarios, and the shared elaboration between professionals of the reference team and specialists who offer the MS, clinical and sanitary guidelines²⁰20. Campos GWS, Domitti AC. Apoio matricial e equipe de referência: uma metodologia para gestão do trabalho interdisciplinar em saúde. Cad Saúde Pública. 2007;23(2):399-407. https://doi.org/10.1590/S0102-311X2007000200016
https://doi.org/10.1590/S0102-311X200700... . Therefore, the constitutive elements of the MS involve services that compose the SUS network and relationships formed between teams to operationalize this support.

Among the successful experiences of MS, the case of mental health can be highlighted, with a reform model of care in shared interprofessional practices associated with co-responsibility between team and users, contributing to the development of actions to decentralize care¹⁷17. Hirdes A. Apoio Matricial em saúde mental: a perspectiva dos especialistas sobre o processo de trabalho. SaúdeDebate. 2018;42(118):656-68. https://doi.org/10.1590/0103-1104201811809
https://doi.org/10.1590/0103-11042018118... ,¹⁸18. Iglesias A, Avellar LZ. Matriciamento em saúde mental: práticas e concepções trazidas por equipes de referência, matriciadores e gestores. CiênSaúde Colet. 2019;24(4):1247-54. https://doi.org/10.1590/1413-81232018244.05362017
https://doi.org/10.1590/1413-81232018244... . The proposal of a matrix model in the health care of older adults is an idea not yet consolidated in the country and it is in line with the needs of health services to enhance care network¹1. Ministério da Saúde (BR). Diretrizes para o cuidado das pessoas idosas no SUS: proposta de modelo de atenção integral à saúde da pessoa idosa: XXX Congresso Nacional de Secretarias Municipais de Saúde [Internet]. Brasília (DF): Ministério da Saúde; 2014 [cited 2020 Dec11]. Available from: https://bvsms.saude.gov.br/bvs/publicacoes/diretrizes_cuidado_pessoa_idosa_sus.pdf
https://bvsms.saude.gov.br/bvs/publicaco... ,³3. Martins AB, D’Avila OP, HilgertJB, Hugo FN. Atenção primária a saúdevoltada as necessidades dos idosos: da teoria à prática. Ciên Saúde Colet. 2014;19(8):3403-16. https://doi.org/10.1590/1413-81232014198.13312013
https://doi.org/10.1590/1413-81232014198... ,⁸8. Nunes LO, Castanheira ERL, Dias A, Zarili TFT, Sanine PR, Mendonça CS, et al. Importância do gerenciamento local para uma atenção primária à saúde nos moldes de Alma-Ata. Rev. Panam Salud Publica. 2018;42:e175. https://doi.org/10.26633/RPSP.2018.175
https://doi.org/10.26633/RPSP.2018.175... .

The referral to the different levels of the health care network of the older adult varies according to the degree of vulnerability identified (fragile and non-fragile)¹1. Ministério da Saúde (BR). Diretrizes para o cuidado das pessoas idosas no SUS: proposta de modelo de atenção integral à saúde da pessoa idosa: XXX Congresso Nacional de Secretarias Municipais de Saúde [Internet]. Brasília (DF): Ministério da Saúde; 2014 [cited 2020 Dec11]. Available from: https://bvsms.saude.gov.br/bvs/publicacoes/diretrizes_cuidado_pessoa_idosa_sus.pdf
https://bvsms.saude.gov.br/bvs/publicaco... ,⁷7. Ministério da Saúde (BR). Orientações técnicas para a implementação de linha de cuidado para atenção integral à saúde da pessoa idosa no Sistema Único de Saúde – SUS [Internet]. Brasília (DF): Ministério da Saúde; 2018 [cited 2020 Dec11]. Available from: http://bvsms.saude.gov.br/bvs/publicacoes/linha_cuidado_atencao_pessoa_idosa.pdf
http://bvsms.saude.gov.br/bvs/publicacoe... ,¹⁰10. Harrison JK, Clegg A, Conroy SP, Young J. Managing frailty as a long-term condition. Age Ageing. 2015;44(5):732-5. https://doi.org/10.1093/ageing/afv085
https://doi.org/10.1093/ageing/afv085... ,¹²12. Ofori-Asenso R, Chin KL, Mazidi M, Zomer E, Ilomaki J, Zullo AR, et al. Global incidence of frailty and prefrailty among community-dwelling older adults: a systematic review and meta-analysis. JAMA Netw Open. 2019;2(8):e198398. https://doi.org/10.1001/jamanetworkopen.2019.8398
https://doi.org/10.1001/jamanetworkopen.... ,¹⁵15. Maia LC, Moraes EN, Costa SM, Caldeira AP. Fragilidade em idosos assistidos por equipes da atenção primária. CiênSaúde Colet.2020;25(12):5041-50. https://doi.org/10.1590/1413-812320202512.04962019
https://doi.org/10.1590/1413-81232020251... ,¹⁶16. Maia LC, Colares TFB, Moraes EN, Costa SM, Caldeira AP. Idosos robustos na atenção primária: fatores associados ao envelhecimento bem-sucedido. RevSaúde Pública. 2020;54:35. https://doi.org/10.11606/s1518-8787.2020054001735
https://doi.org/10.11606/s1518-8787.2020... ,²²22. Lourenço RA, Moreira VG, Mello RGB, Santos IS, Lin SM, Pinto ALF, et al. Consenso brasileiro de fragilidade em idosos: conceitos, epidemiologia e instrumentos de avaliação. GeriatrGerontolAging. 2018;12(2):121-35. https://doi.org/10.5327/Z2447-211520181800023
https://doi.org/10.5327/Z2447-2115201818... . For the screening of clinical-functional strata in this population, there are several instruments¹⁵15. Maia LC, Moraes EN, Costa SM, Caldeira AP. Fragilidade em idosos assistidos por equipes da atenção primária. CiênSaúde Colet.2020;25(12):5041-50. https://doi.org/10.1590/1413-812320202512.04962019
https://doi.org/10.1590/1413-81232020251... ,¹⁶16. Maia LC, Colares TFB, Moraes EN, Costa SM, Caldeira AP. Idosos robustos na atenção primária: fatores associados ao envelhecimento bem-sucedido. RevSaúde Pública. 2020;54:35. https://doi.org/10.11606/s1518-8787.2020054001735
https://doi.org/10.11606/s1518-8787.2020... ,²²22. Lourenço RA, Moreira VG, Mello RGB, Santos IS, Lin SM, Pinto ALF, et al. Consenso brasileiro de fragilidade em idosos: conceitos, epidemiologia e instrumentos de avaliação. GeriatrGerontolAging. 2018;12(2):121-35. https://doi.org/10.5327/Z2447-211520181800023
https://doi.org/10.5327/Z2447-2115201818... ,²⁶26. Faller JW, Pereira DN, Souza S, Nampo FK, Orlandi FDS, Matumoto S. Instruments for the detection of frailty syndrome in older adults: a systematic review. PLoS One. 2019;14(4):e0216166. https://doi.org/10.1371/journal.pone.0216166
https://doi.org/10.1371/journal.pone.021... , including the clinical-functional vulnerability index (IVCF-20), which was developed and validated in Brazil and it has a good correlation with other instruments used internationally ¹⁵15. Maia LC, Moraes EN, Costa SM, Caldeira AP. Fragilidade em idosos assistidos por equipes da atenção primária. CiênSaúde Colet.2020;25(12):5041-50. https://doi.org/10.1590/1413-812320202512.04962019
https://doi.org/10.1590/1413-81232020251... ,¹⁶16. Maia LC, Colares TFB, Moraes EN, Costa SM, Caldeira AP. Idosos robustos na atenção primária: fatores associados ao envelhecimento bem-sucedido. RevSaúde Pública. 2020;54:35. https://doi.org/10.11606/s1518-8787.2020054001735
https://doi.org/10.11606/s1518-8787.2020... ,²⁶26. Faller JW, Pereira DN, Souza S, Nampo FK, Orlandi FDS, Matumoto S. Instruments for the detection of frailty syndrome in older adults: a systematic review. PLoS One. 2019;14(4):e0216166. https://doi.org/10.1371/journal.pone.0216166
https://doi.org/10.1371/journal.pone.021... ,²⁷27. Moraes EN, Carmo JA, Moraes FL, Azevedo RS, Machado CJ, Montilla DER. Índice de Vulnerabilidade Clínico Funcional-20 (IVCF-20): reconhecimento rápido do idoso frágil. Rev SaúdePública. 2016;50:81. https://doi.org/10.1590/s1518-8787.2016050006963
https://doi.org/10.1590/s1518-8787.20160... . Due to the ease of application, the IVCF-20 is a good tool for the FHS teams in the evaluation and follow-up of older adults¹⁵15. Maia LC, Moraes EN, Costa SM, Caldeira AP. Fragilidade em idosos assistidos por equipes da atenção primária. CiênSaúde Colet.2020;25(12):5041-50. https://doi.org/10.1590/1413-812320202512.04962019
https://doi.org/10.1590/1413-81232020251... ,¹⁶16. Maia LC, Colares TFB, Moraes EN, Costa SM, Caldeira AP. Idosos robustos na atenção primária: fatores associados ao envelhecimento bem-sucedido. RevSaúde Pública. 2020;54:35. https://doi.org/10.11606/s1518-8787.2020054001735
https://doi.org/10.11606/s1518-8787.2020... . This study analyzes the effect of matrix support on health to older adults assisted by the FHS based on the level of frailty measurement, according to the IVCF-20.

METHODS

This is a randomized controlled community trial (RCT), conducted in the municipality of Montes Claros, in the Southeast region of Brazil, in 2018. At the time of the study, the urban population was approximately 400,000 inhabitants and it recorded more than 80% coverage by the family health strategy, with 121 teams. Considering the need for contexts with low turnover among health professionals, the research was developed in scope centers of the Medical Residency Program in Family and Community Medicine (PRMMFC – Programa de Residência Médica em Medicina de Família e Comunidade). During this period, the municipality had 12 regional centers, each composed of three teams, and each team was responsible for five micro-areas. Two poles were drawn, between the 12 centers, for immediate intervention, and two poles for control group, using the random number generator program (randomnumbergeneration.intemodino.com). The poles drawn presented similarities in relation to the composition of the teams, they were areas of coverage of the PRMMFC and presented sociodemographic similarity. The definition of teams for intervention or control was randomized by simple draw. The intervention unit was the health team, and the outcome was measured in the older population assisted by the respective teams.

For the sample estimation of the number of older adults followed in each group, the type 1 error (alpha) of 5% and a 80% power of the study in a two-tailed test were considered. The clinical-functional vulnerability rate (frailty) of 25% was considered and, after matrix support, 10%, that is reduction of 15% occurred. Thus, the proposed sample was defined in at least 150 older adults in each study group: intervention and control.

Based on the random selection of health teams, the inclusion of older adults was also performed randomly, based on the relationship of people aged 60 years or older assisted by the teams of the Residence of Family and Community Medicine, respecting eligibility criteria for the study. Older adults able to answer the questionnaires and, when disabled, those older adults who had caregivers/guardians available during the visit to provide the requested information participated in the study. The data collection was performed at home, in the morning, evening or night shifts and on all days of the week, preferably with prior scheduling. Older adults not located in at least three visits, on different days and times, were replaced by draw.

The Consort diagram (Consolidated Standards of Reporting Trials) (Figure 1) shows the details of inclusion, allocation, and follow-up of the study participants, in the intervention group (with matrix support to the FHS) and in the control group (without matrix support to the FHS). The 402 participants eligible to compose the sample of older adults were distributed in: 197 in the intervention group (IG) and 205 in the control group (CG). The higher number of participants in relation to the sample estimation was included considering the possibility of losses, which did not occur during the study period.

The selected older adults answered the IVCF-20, a screening questionnaire with multidimensional character, rapid application (five to 10 minutes) and easy interpretation of the result, which can be performed by all the health team, that probably contributed to positive results in the context of recognition and multiprofessional management of frailty in PHC¹⁵15. Maia LC, Moraes EN, Costa SM, Caldeira AP. Fragilidade em idosos assistidos por equipes da atenção primária. CiênSaúde Colet.2020;25(12):5041-50. https://doi.org/10.1590/1413-812320202512.04962019
https://doi.org/10.1590/1413-81232020251... ,¹⁶16. Maia LC, Colares TFB, Moraes EN, Costa SM, Caldeira AP. Idosos robustos na atenção primária: fatores associados ao envelhecimento bem-sucedido. RevSaúde Pública. 2020;54:35. https://doi.org/10.11606/s1518-8787.2020054001735
https://doi.org/10.11606/s1518-8787.2020... ,²⁶26. Faller JW, Pereira DN, Souza S, Nampo FK, Orlandi FDS, Matumoto S. Instruments for the detection of frailty syndrome in older adults: a systematic review. PLoS One. 2019;14(4):e0216166. https://doi.org/10.1371/journal.pone.0216166
https://doi.org/10.1371/journal.pone.021... .

This instrument includes domains considered predictors of clinical and functional vulnerability and adverse outcomes, such as functional decline and death in the older adults¹⁵15. Maia LC, Moraes EN, Costa SM, Caldeira AP. Fragilidade em idosos assistidos por equipes da atenção primária. CiênSaúde Colet.2020;25(12):5041-50. https://doi.org/10.1590/1413-812320202512.04962019
https://doi.org/10.1590/1413-81232020251... ,¹⁶16. Maia LC, Colares TFB, Moraes EN, Costa SM, Caldeira AP. Idosos robustos na atenção primária: fatores associados ao envelhecimento bem-sucedido. RevSaúde Pública. 2020;54:35. https://doi.org/10.11606/s1518-8787.2020054001735
https://doi.org/10.11606/s1518-8787.2020... ,²⁶26. Faller JW, Pereira DN, Souza S, Nampo FK, Orlandi FDS, Matumoto S. Instruments for the detection of frailty syndrome in older adults: a systematic review. PLoS One. 2019;14(4):e0216166. https://doi.org/10.1371/journal.pone.0216166
https://doi.org/10.1371/journal.pone.021... ,²⁷27. Moraes EN, Carmo JA, Moraes FL, Azevedo RS, Machado CJ, Montilla DER. Índice de Vulnerabilidade Clínico Funcional-20 (IVCF-20): reconhecimento rápido do idoso frágil. Rev SaúdePública. 2016;50:81. https://doi.org/10.1590/s1518-8787.2016050006963
https://doi.org/10.1590/s1518-8787.20160... . Moreover, these instruments considers the following dimensions: self-perceived health, activities of daily living (ADL), cognition, mood, mobility, communication, and multiple comorbidities. The IVCF-20 provides the creation of a score that defines the risk of frailty. The final score to stratify frailty in this study was dichotomized in fragile (score ≥15) and non-fragile (score < 15)¹⁵15. Maia LC, Moraes EN, Costa SM, Caldeira AP. Fragilidade em idosos assistidos por equipes da atenção primária. CiênSaúde Colet.2020;25(12):5041-50. https://doi.org/10.1590/1413-812320202512.04962019
https://doi.org/10.1590/1413-81232020251... ,¹⁶16. Maia LC, Colares TFB, Moraes EN, Costa SM, Caldeira AP. Idosos robustos na atenção primária: fatores associados ao envelhecimento bem-sucedido. RevSaúde Pública. 2020;54:35. https://doi.org/10.11606/s1518-8787.2020054001735
https://doi.org/10.11606/s1518-8787.2020... ,²²22. Lourenço RA, Moreira VG, Mello RGB, Santos IS, Lin SM, Pinto ALF, et al. Consenso brasileiro de fragilidade em idosos: conceitos, epidemiologia e instrumentos de avaliação. GeriatrGerontolAging. 2018;12(2):121-35. https://doi.org/10.5327/Z2447-211520181800023
https://doi.org/10.5327/Z2447-2115201818... ,²⁶26. Faller JW, Pereira DN, Souza S, Nampo FK, Orlandi FDS, Matumoto S. Instruments for the detection of frailty syndrome in older adults: a systematic review. PLoS One. 2019;14(4):e0216166. https://doi.org/10.1371/journal.pone.0216166
https://doi.org/10.1371/journal.pone.021... ,²⁷27. Moraes EN, Carmo JA, Moraes FL, Azevedo RS, Machado CJ, Montilla DER. Índice de Vulnerabilidade Clínico Funcional-20 (IVCF-20): reconhecimento rápido do idoso frágil. Rev SaúdePública. 2016;50:81. https://doi.org/10.1590/s1518-8787.2016050006963
https://doi.org/10.1590/s1518-8787.20160... . In addition to the IVCF-20, information on age, gender, and income of the older adults was collected.

Data collection was performed by a specially trained team composed of nursing professionals and medical students. Prior to the beginning of the research, a pilot project was conducted, in a different area, for the calibration of the interviewers. Data collection occurred before (baseline) and six months after the end of the intervention (final line) by the training of the FHS professionals to support the older adults’ matrix health support. The interviewers were the same, both in the pre-intervention and in the post-intervention, and they were not aware of which health teams would be under intervention or control.

The training of health teams was carried out during six months in the PRMMFC centers, with monthly meetings coordinated by a geriatric physician working in the SUS. A modular training schedule was established based on the structuring axes of the older adults health⁷7. Ministério da Saúde (BR). Orientações técnicas para a implementação de linha de cuidado para atenção integral à saúde da pessoa idosa no Sistema Único de Saúde – SUS [Internet]. Brasília (DF): Ministério da Saúde; 2018 [cited 2020 Dec11]. Available from: http://bvsms.saude.gov.br/bvs/publicacoes/linha_cuidado_atencao_pessoa_idosa.pdf
http://bvsms.saude.gov.br/bvs/publicacoe... , without affecting the service of the health units selected for intervention. The team was called in advance by the Municipal Health Department and, the by phone, they received a confirmation of the meeting by the person in charge of the MS. Professionals who were members of each pole participated in the educational activities: three from medicine, six from nursing, and 15 community health agents. All professionals from the categories described above, linked to the selected poles, were considered eligible for participation in the intervention. The frequency of participation was 100%.

This proposal was based on the way of mental health matrix support, already carried out throughout the municipality PHC. Thus, each monthly meeting lasted four hours, based on tutorial actions, dialogued class, discussion of clinical cases, as well as care and construction of therapeutic plans in group. It is emphasized that the educational and care planning of the meetings valued the teams’ demands, based on discussion of clinical cases of the older adults with clinical-functional stratification, followed by the elaboration and shared monitoring of care plans, with the management of the user’s health by PHC teams.

At first, a survey was conducted on the main problems presented by the older adults in the IG: forgetfulness, falls, loss of functionality, polypharmacy, iatrogenic, lack of family support, and urinary incontinence. The themes aggregated structuring axes of integral care of the older adults (giants of geriatrics)⁷7. Ministério da Saúde (BR). Orientações técnicas para a implementação de linha de cuidado para atenção integral à saúde da pessoa idosa no Sistema Único de Saúde – SUS [Internet]. Brasília (DF): Ministério da Saúde; 2018 [cited 2020 Dec11]. Available from: http://bvsms.saude.gov.br/bvs/publicacoes/linha_cuidado_atencao_pessoa_idosa.pdf
http://bvsms.saude.gov.br/bvs/publicacoe... – 1) frailty syndrome; 2) cognitive disability; 3) postural instability, falls, and immobility; 4) iatrogenic; and 5) incontinence – topics that compose the IVCF-20 dimensions²⁷27. Moraes EN, Carmo JA, Moraes FL, Azevedo RS, Machado CJ, Montilla DER. Índice de Vulnerabilidade Clínico Funcional-20 (IVCF-20): reconhecimento rápido do idoso frágil. Rev SaúdePública. 2016;50:81. https://doi.org/10.1590/s1518-8787.2016050006963
https://doi.org/10.1590/s1518-8787.20160... . Thus, the monthly programming of the matrix experience in health of older adults was carried out, regarding the demands of the teams. We emphasize that the e-mail and telephone number of the tutor was available to the IG.

Descriptive statistics were performed, followed by bivariate analysis by Pearson’s chi-square test to compare the variables of IVCF-20 before and after the intervention, assuming a 5% significance level. The relative risk (RR) was estimated for the general classification of the frailty index based on the final scores of the instrument (categorized into frail and non-frail) and it was also estimated for the variables that compose the IVCF-20 dimensions. Data were analyzed with the IBM^® SPSS^®software (version 22.0).

This study was conducted in accordance with Resolution 466/12 of the National Health Council, Brazilian Ministry of Health, opinion No. 1,628,652. It was also registered on the Brazilian Clinical Trials Registration Platform (ReBEC –Plataforma de Registro Brasileiro de Ensaios Clínicos)^aaAvailable from: http://www.ensaiosclinicos.gov.br/rg/RBR-7b9xff/ , under registration number BR-7b9xff.

All participants were duly informed about the research and presented their consent by signing the free and informed consent form. For those who could not sign, a collection of fingerprints was performed in a specific area of the consent form. Anonymity and confidentiality of the information provided were ensured, this information was exclusively used for research purposes.

We emphasize that, with the completion of post-intervention data collection, the other health teams received the same educational intervention. Throughout the research process, the older adults classified with a high degree of frailty were referred for specific follow-up (secondary care). During the study, the older adults of the CG continued to be assisted and monitored by the FHS teams to which they were enrolled, using the usual resources available in the municipality.

RESULTS

Table 1 presents the comparison of some characteristics of IG and CG in the baseline of the study. It was noticed that most older adults were female, aged between 60 and 74 years and with income of up to two minimum wages in force during the period of data collection. These variables were defined for the analysis of comparability of the groups, not registering statistically significant differences between demographic and economic variables (gender, age, and income) of the groups, in the baseline of the study.

Table 2 presents the stratification of the older adults regarding clinical and functional vulnerability, measured by IVCF-20, at baseline and at the end of the study. After the intervention, the number of frail individuals swelled in both groups. However, the IG presented a lower percentage (21.7%) of frail individuals than the CG (RR = 0.74; 95%CI = 0.60-0.91), demonstrating an intervention efficacy of 26%.

The comparison of IVCF-20 variables between the groups at baseline and at the end of the study is presented in Table 3. At baseline, the groups were homogeneous in relation to the items “self-perception of positive health,” “independence for instrumental and basic daily living activities (ADL),” “mood,” “body mass index (BMI) ≥ 22,” “gait speed ≤ 5,” “no difficulty walking,” “no hearing problem,” and “polypathology” (presence of five or more diseases). The groups were not homogeneous regarding “cognition,” “no change of reach, grip and pincer,” “no weight loss,” “calf circumference ≥ 31,” “without two or more falls in the last year,” “no urinary incontinence,” “no vision problem,” “no polypharmacy” (use of five or more medications), and “no hospitalization in the last six months.” After intervention, there was an increase in the proportion of independent older adults for instrumental ADL in the intervention group, with a statistically significant difference in relation to the control group (RR = 1.16; 95%CI = 1.07-1.26).

Regarding cognition, the older adults in the intervention group also presented more positive responses than those of the CG for the items “forgetfulness has not worsened in the recent months” (RR = 1.17; 95%CI = 1.11-1.22) and “forgetfulness did not prevent daily activities” (RR = 1.07; 95%CI = 1.03-1.11). On mood, older adults in the intervention group presented higher percentages for “no manifestation of sadness, discouragement or hopelessness” (RR = 1.11; 95%CI = 1.01-1.21) and also “had no loss of interest or pleasure” (RR = 1.19; 95%CI = 1.13-1.27). In the mobility item, most older adults in the IG “did not present alteration of reach, grip, and pincer” (RR = 1.05; 95%CI = 1.03-1.08), “had no weight loss” (RR = 1.06; 95%CI = 1.01-1.11), maintained the “calf circumference ≥ 31” (RR = 1.04; 95%CI =1.01-1.07) and they did not have “urinary incontinence” (RR = 1.16; 95%CI = 1.08-1.26). Among the variables of the item communication, “no vision problem” was more frequent among the older adults in the IG, also with a statistically significant difference (RR = 1.14; 95%CI = 1.06-1.28). In the dimension of multiple comorbidities, there was a favorable difference for the IG in the item “without polypathologies” (RR = 1.23 (95%CI = 1.16-1.31).

Some items did not show changes after the intervention: “self-perceived positive health,” “independence for basic ADL,” “no observation of any family member or friend about forgetfulness,” “walking speed ≤ 5,” “no difficult to walk,” “without two or more falls in the last year,” “no hearing problems,” “no polypharmacy,” and “no hospitalization in the last six months.”

DISCUSSION

The results of the study showed that the effect of health matrix actions for older adults assisted by FHS teams on the dimensions of frailty measured with the IVCF-20 was positive, with an improvement in the percentages for most items and dimensions assessed. The percentage of frailty in the group whose professionals participated in the MS, at the end of the study, was lower than that of the control group. Thus, we emphasize that the implementation of care models supporting the identification and management of chronic conditions, such as frailty syndrome, can contribute to the improvement and/or maintenance of the clinical-functional stratum of older adults in the FHS¹³13. Kojima G, Liljas AEM, Iliffe S. Frailty syndrome: implications and challenges for health care policy. Risk ManagHealthc Policy. 2019;12:23-30. https://doi.org/10.2147/RMHP.S168750
https://doi.org/10.2147/RMHP.S168750... . The development of pedagogical and clinical-care technical actions by health professionals can improve or delay negative repercussions on the functionality and quality of life of the older adults¹1. Ministério da Saúde (BR). Diretrizes para o cuidado das pessoas idosas no SUS: proposta de modelo de atenção integral à saúde da pessoa idosa: XXX Congresso Nacional de Secretarias Municipais de Saúde [Internet]. Brasília (DF): Ministério da Saúde; 2014 [cited 2020 Dec11]. Available from: https://bvsms.saude.gov.br/bvs/publicacoes/diretrizes_cuidado_pessoa_idosa_sus.pdf
https://bvsms.saude.gov.br/bvs/publicaco... ,²2. World Health Organization. World report on ageing and health 2015 [Internet]. Geneva: WHO; 2015 [cited 2020 Dec11]. Available from: http://www.who.int/ageing/events/world-report-2015-launch/en/
http://www.who.int/ageing/events/world-r... ,⁴4. Beard JR, Officer A, Carvalho IA, Sadana R, Pot AM, Michel JP, et al. The World report on ageing and health: a policy framework for healthy ageing. Lancet. 2016;387(10033):2145-54. https://doi.org/10.1016/s0140-6736(15)00516-4
https://doi.org/10.1016/s0140-6736(15)00... ,⁷7. Ministério da Saúde (BR). Orientações técnicas para a implementação de linha de cuidado para atenção integral à saúde da pessoa idosa no Sistema Único de Saúde – SUS [Internet]. Brasília (DF): Ministério da Saúde; 2018 [cited 2020 Dec11]. Available from: http://bvsms.saude.gov.br/bvs/publicacoes/linha_cuidado_atencao_pessoa_idosa.pdf
http://bvsms.saude.gov.br/bvs/publicacoe... .

The results found are in accordance with the literature, that attests to the need for early identification of frailty as an essential point for understanding its dynamic and unpredictable evolution in the course of long-term health, emphasizing the benefit of timely interventions in order to reduce the individual and collective burden²⁸28. Kojima G, Taniguchi Y, Iliffe S, Jivraj S, Walters K. Transitions between frailty states among community-dwelling older people: a systematic review and meta-analysis. Ageing Res Rev. 2019;50:81-8. https://doi.org/10.1016/j.arr.2019.01.010
https://doi.org/10.1016/j.arr.2019.01.01... . Frail older adults present reduction of homeostatic reserve and/or ability to adapt to injuries, being predisposed to greater vulnerability and functional impairment¹³13. Kojima G, Liljas AEM, Iliffe S. Frailty syndrome: implications and challenges for health care policy. Risk ManagHealthc Policy. 2019;12:23-30. https://doi.org/10.2147/RMHP.S168750
https://doi.org/10.2147/RMHP.S168750... ,²³23. Morley JE, Vellas B, van 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.... ,²⁴24. Rockwood K, Mitnitski A. Frailty defined by deficit accumulation and geriatric medicine defined by frailty. ClinGeriatr Med. 2011;27(1):17-26. https://doi.org/10.1016/j.cger.2010.08.008
https://doi.org/10.1016/j.cger.2010.08.0... ,²⁸28. Kojima G, Taniguchi Y, Iliffe S, Jivraj S, Walters K. Transitions between frailty states among community-dwelling older people: a systematic review and meta-analysis. Ageing Res Rev. 2019;50:81-8. https://doi.org/10.1016/j.arr.2019.01.010
https://doi.org/10.1016/j.arr.2019.01.01... ,³⁰30. Feng Z, Lugtenberg M, Franse C, Fang X, Hu S, Jin C, Raat H, et al. Risk factors and protective factors associated with incident or increase of frailty among community-dwelling older adults: a systematic review of longitudinal studies. PLoSOne. 2017;12(6):e0178383. https://doi.org/10.1371/journal.pone.0178383
https://doi.org/10.1371/journal.pone.017... ,³¹31. Silva SLA, Neri AL, Ferrioli E, Lourenço RA, Dias RC. Fenótipo de fragilidade: influência de cada item na determinação da fragilidade em idosos comunitários – Rede Fibra. Ciên Saúde Colet. 2016;21(11):3483-92. https://doi.org/10.1590/1413-812320152111.23292015
https://doi.org/10.1590/1413-81232015211... . The screening of the different strata of clinical and functional vulnerability in the older adults of PHC, with the IVCF, was the starting point for the planning of the matrix support of this research.

Regarding the interviewees’ data, in the baseline, “age,” “sex,” and “income” were the variables that showed similarities and comparability between the control and intervention groups. At the end of the intervention, there was an increase in the percentage of instrumental ADL of older adults in the IG, in addition to improving the responses in the cognition and mood dimensions. These results can be explained by the improvement of the functionality in older adults due to a possible approach of the variables mood and cognition, with favorable reflexes in their independence and reduction of vulnerability. The literature correlates the mental domain, physical capacity, and frailty, mentioning risks and consequences of this association regarding the worsening of the individual’s health and quality of life⁷7. Ministério da Saúde (BR). Orientações técnicas para a implementação de linha de cuidado para atenção integral à saúde da pessoa idosa no Sistema Único de Saúde – SUS [Internet]. Brasília (DF): Ministério da Saúde; 2018 [cited 2020 Dec11]. Available from: http://bvsms.saude.gov.br/bvs/publicacoes/linha_cuidado_atencao_pessoa_idosa.pdf
http://bvsms.saude.gov.br/bvs/publicacoe... ,¹⁵15. Maia LC, Moraes EN, Costa SM, Caldeira AP. Fragilidade em idosos assistidos por equipes da atenção primária. CiênSaúde Colet.2020;25(12):5041-50. https://doi.org/10.1590/1413-812320202512.04962019
https://doi.org/10.1590/1413-81232020251... ,²²22. Lourenço RA, Moreira VG, Mello RGB, Santos IS, Lin SM, Pinto ALF, et al. Consenso brasileiro de fragilidade em idosos: conceitos, epidemiologia e instrumentos de avaliação. GeriatrGerontolAging. 2018;12(2):121-35. https://doi.org/10.5327/Z2447-211520181800023
https://doi.org/10.5327/Z2447-2115201818... . Furthermore, promoting actions to preserve the autonomy and functional capacity of older adults reduces the adverse outcomes of frailty, because functional loss is always pathological and requires careful investigation¹1. Ministério da Saúde (BR). Diretrizes para o cuidado das pessoas idosas no SUS: proposta de modelo de atenção integral à saúde da pessoa idosa: XXX Congresso Nacional de Secretarias Municipais de Saúde [Internet]. Brasília (DF): Ministério da Saúde; 2014 [cited 2020 Dec11]. Available from: https://bvsms.saude.gov.br/bvs/publicacoes/diretrizes_cuidado_pessoa_idosa_sus.pdf
https://bvsms.saude.gov.br/bvs/publicaco... ,⁴4. Beard JR, Officer A, Carvalho IA, Sadana R, Pot AM, Michel JP, et al. The World report on ageing and health: a policy framework for healthy ageing. Lancet. 2016;387(10033):2145-54. https://doi.org/10.1016/s0140-6736(15)00516-4
https://doi.org/10.1016/s0140-6736(15)00... ,⁷7. Ministério da Saúde (BR). Orientações técnicas para a implementação de linha de cuidado para atenção integral à saúde da pessoa idosa no Sistema Único de Saúde – SUS [Internet]. Brasília (DF): Ministério da Saúde; 2018 [cited 2020 Dec11]. Available from: http://bvsms.saude.gov.br/bvs/publicacoes/linha_cuidado_atencao_pessoa_idosa.pdf
http://bvsms.saude.gov.br/bvs/publicacoe... ,⁹9. Turner G, Clegg A. Best practice guidelines for the management of frailty: a British Geriatrics Society, Age UK and Royal College of General Practitioners report. Age Ageing. 2014;43(6):744-7. https://doi.org/10.1093/ageing/afu138
https://doi.org/10.1093/ageing/afu138... ,¹⁰10. Harrison JK, Clegg A, Conroy SP, Young J. Managing frailty as a long-term condition. Age Ageing. 2015;44(5):732-5. https://doi.org/10.1093/ageing/afv085
https://doi.org/10.1093/ageing/afv085... ,¹⁴14. Gwyther H, Shaw R, Dauden EAJ, D’Avanzo B, Kurpas D, Bujnowska-Fedak M, et al. Understanding frailty: a qualitative study of European healthcare policy-makers’ approaches to frailty screening and management. BMJ Open. 2018;8(1):e018653. https://doi.org/10.1136/bmjopen-2017-018653
https://doi.org/10.1136/bmjopen-2017-018... ,¹⁵15. Maia LC, Moraes EN, Costa SM, Caldeira AP. Fragilidade em idosos assistidos por equipes da atenção primária. CiênSaúde Colet.2020;25(12):5041-50. https://doi.org/10.1590/1413-812320202512.04962019
https://doi.org/10.1590/1413-81232020251... ,²²22. Lourenço RA, Moreira VG, Mello RGB, Santos IS, Lin SM, Pinto ALF, et al. Consenso brasileiro de fragilidade em idosos: conceitos, epidemiologia e instrumentos de avaliação. GeriatrGerontolAging. 2018;12(2):121-35. https://doi.org/10.5327/Z2447-211520181800023
https://doi.org/10.5327/Z2447-2115201818... .

There was also an improvement in the intervention group in relation to the control group of the percentage in topics of health determinants of the IVCF-20: 1) mobility (“did not present alteration of reach, grip and pincer,” “had no weight loss,” “calf circumference ≥ 31,” and “no urinary incontinence”); 2) communication (“has no vision problem”); and 3) multiple comorbidities (“did not present polypathologies”). Notably, these dimensions were already significantly better in the intervention before training, however it is emphasized that they remain statistically significant at the end. It is also noteworthy the need for accurate investigation of mobility issues and in the evaluation of the older adults, especially incontinence¹⁵15. Maia LC, Moraes EN, Costa SM, Caldeira AP. Fragilidade em idosos assistidos por equipes da atenção primária. CiênSaúde Colet.2020;25(12):5041-50. https://doi.org/10.1590/1413-812320202512.04962019
https://doi.org/10.1590/1413-81232020251... ,²⁴24. Rockwood K, Mitnitski A. Frailty defined by deficit accumulation and geriatric medicine defined by frailty. ClinGeriatr Med. 2011;27(1):17-26. https://doi.org/10.1016/j.cger.2010.08.008
https://doi.org/10.1016/j.cger.2010.08.0... ,³²32. Carneiro JA, Lima CA, Costa FM, Caldeira AP. Cuidados em saúde estão associados à piora da fragilidade em idosos comunitários. Rev Saúde Pública. 2019;53:32. https://doi.org/10.11606/s1518-8787.2019053000829
https://doi.org/10.11606/s1518-8787.2019... .

Therefore, these indicators complement the IVCF-20 in the screening of clinical and functional vulnerability of the older adults and the identification of frailty, which represents a dynamic, multifactorial clinical state resulting from the sum of deficits¹⁵15. Maia LC, Moraes EN, Costa SM, Caldeira AP. Fragilidade em idosos assistidos por equipes da atenção primária. CiênSaúde Colet.2020;25(12):5041-50. https://doi.org/10.1590/1413-812320202512.04962019
https://doi.org/10.1590/1413-81232020251... ,¹⁶16. Maia LC, Colares TFB, Moraes EN, Costa SM, Caldeira AP. Idosos robustos na atenção primária: fatores associados ao envelhecimento bem-sucedido. RevSaúde Pública. 2020;54:35. https://doi.org/10.11606/s1518-8787.2020054001735
https://doi.org/10.11606/s1518-8787.2020... ,²⁴24. Rockwood K, Mitnitski A. Frailty defined by deficit accumulation and geriatric medicine defined by frailty. ClinGeriatr Med. 2011;27(1):17-26. https://doi.org/10.1016/j.cger.2010.08.008
https://doi.org/10.1016/j.cger.2010.08.0... ,²⁵25. Cesari M, Prince M, Thiyagarajan JA, CarvalhoIA, Bernabei R, Chan P, et al. Frailty: an emerging public health priority. J Am Med Dir Assoc. 2016;17(3):188-92. https://doi.org/10.1016/j.jamda.2015.12.016
https://doi.org/10.1016/j.jamda.2015.12.... ,³¹31. Silva SLA, Neri AL, Ferrioli E, Lourenço RA, Dias RC. Fenótipo de fragilidade: influência de cada item na determinação da fragilidade em idosos comunitários – Rede Fibra. Ciên Saúde Colet. 2016;21(11):3483-92. https://doi.org/10.1590/1413-812320152111.23292015
https://doi.org/10.1590/1413-81232015211... that usually culminate in hostile outcomes to affected individuals and to the public system²2. World Health Organization. World report on ageing and health 2015 [Internet]. Geneva: WHO; 2015 [cited 2020 Dec11]. Available from: http://www.who.int/ageing/events/world-report-2015-launch/en/
http://www.who.int/ageing/events/world-r... ,⁴4. Beard JR, Officer A, Carvalho IA, Sadana R, Pot AM, Michel JP, et al. The World report on ageing and health: a policy framework for healthy ageing. Lancet. 2016;387(10033):2145-54. https://doi.org/10.1016/s0140-6736(15)00516-4
https://doi.org/10.1016/s0140-6736(15)00... ,⁷7. Ministério da Saúde (BR). Orientações técnicas para a implementação de linha de cuidado para atenção integral à saúde da pessoa idosa no Sistema Único de Saúde – SUS [Internet]. Brasília (DF): Ministério da Saúde; 2018 [cited 2020 Dec11]. Available from: http://bvsms.saude.gov.br/bvs/publicacoes/linha_cuidado_atencao_pessoa_idosa.pdf
http://bvsms.saude.gov.br/bvs/publicacoe... ,¹⁵15. Maia LC, Moraes EN, Costa SM, Caldeira AP. Fragilidade em idosos assistidos por equipes da atenção primária. CiênSaúde Colet.2020;25(12):5041-50. https://doi.org/10.1590/1413-812320202512.04962019
https://doi.org/10.1590/1413-81232020251... ,²³23. Morley JE, Vellas B, van 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.... ,²⁵25. Cesari M, Prince M, Thiyagarajan JA, CarvalhoIA, Bernabei R, Chan P, et al. Frailty: an emerging public health priority. J Am Med Dir Assoc. 2016;17(3):188-92. https://doi.org/10.1016/j.jamda.2015.12.016
https://doi.org/10.1016/j.jamda.2015.12.... ,³²32. Carneiro JA, Lima CA, Costa FM, Caldeira AP. Cuidados em saúde estão associados à piora da fragilidade em idosos comunitários. Rev Saúde Pública. 2019;53:32. https://doi.org/10.11606/s1518-8787.2019053000829
https://doi.org/10.11606/s1518-8787.2019... . Studies show the association of frailty with reduced mobility, weight loss¹⁵15. Maia LC, Moraes EN, Costa SM, Caldeira AP. Fragilidade em idosos assistidos por equipes da atenção primária. CiênSaúde Colet.2020;25(12):5041-50. https://doi.org/10.1590/1413-812320202512.04962019
https://doi.org/10.1590/1413-81232020251... ,³⁰30. Feng Z, Lugtenberg M, Franse C, Fang X, Hu S, Jin C, Raat H, et al. Risk factors and protective factors associated with incident or increase of frailty among community-dwelling older adults: a systematic review of longitudinal studies. PLoSOne. 2017;12(6):e0178383. https://doi.org/10.1371/journal.pone.0178383
https://doi.org/10.1371/journal.pone.017... ,³¹31. Silva SLA, Neri AL, Ferrioli E, Lourenço RA, Dias RC. Fenótipo de fragilidade: influência de cada item na determinação da fragilidade em idosos comunitários – Rede Fibra. Ciên Saúde Colet. 2016;21(11):3483-92. https://doi.org/10.1590/1413-812320152111.23292015
https://doi.org/10.1590/1413-81232015211... , presence of polypathologies¹⁵15. Maia LC, Moraes EN, Costa SM, Caldeira AP. Fragilidade em idosos assistidos por equipes da atenção primária. CiênSaúde Colet.2020;25(12):5041-50. https://doi.org/10.1590/1413-812320202512.04962019
https://doi.org/10.1590/1413-81232020251... ,²⁴24. Rockwood K, Mitnitski A. Frailty defined by deficit accumulation and geriatric medicine defined by frailty. ClinGeriatr Med. 2011;27(1):17-26. https://doi.org/10.1016/j.cger.2010.08.008
https://doi.org/10.1016/j.cger.2010.08.0... ,²⁵25. Cesari M, Prince M, Thiyagarajan JA, CarvalhoIA, Bernabei R, Chan P, et al. Frailty: an emerging public health priority. J Am Med Dir Assoc. 2016;17(3):188-92. https://doi.org/10.1016/j.jamda.2015.12.016
https://doi.org/10.1016/j.jamda.2015.12.... ,³²32. Carneiro JA, Lima CA, Costa FM, Caldeira AP. Cuidados em saúde estão associados à piora da fragilidade em idosos comunitários. Rev Saúde Pública. 2019;53:32. https://doi.org/10.11606/s1518-8787.2019053000829
https://doi.org/10.11606/s1518-8787.2019... , incontinence and impaired vision, in addition to other geriatric syndromes¹⁵15. Maia LC, Moraes EN, Costa SM, Caldeira AP. Fragilidade em idosos assistidos por equipes da atenção primária. CiênSaúde Colet.2020;25(12):5041-50. https://doi.org/10.1590/1413-812320202512.04962019
https://doi.org/10.1590/1413-81232020251... ,³⁰30. Feng Z, Lugtenberg M, Franse C, Fang X, Hu S, Jin C, Raat H, et al. Risk factors and protective factors associated with incident or increase of frailty among community-dwelling older adults: a systematic review of longitudinal studies. PLoSOne. 2017;12(6):e0178383. https://doi.org/10.1371/journal.pone.0178383
https://doi.org/10.1371/journal.pone.017... ,³¹31. Silva SLA, Neri AL, Ferrioli E, Lourenço RA, Dias RC. Fenótipo de fragilidade: influência de cada item na determinação da fragilidade em idosos comunitários – Rede Fibra. Ciên Saúde Colet. 2016;21(11):3483-92. https://doi.org/10.1590/1413-812320152111.23292015
https://doi.org/10.1590/1413-81232015211... .

It is not possible to evaluate how the MS separately influenced each of the dimensions measured by the IVCF-20. Although these relationships are extensively discussed in the literature, the aim of study was to evaluate possible changes in the frailty indicator, which were restricted to some aspects (instrumental activities and cognition), but not to all components of the frailty index used. Overall, the intervention may have contributed to the recognition of vulnerability strata, providing opportunities for sensitization and decision-making based on care measures centered on this age group, capable of improving the functionality of the older adults in the IG.

The essence of this work was the approximation between primary care professionals (PHC teams) and secondary care (geriatrics of the SUS). The sensitization of professionals of the FHS and the co-management of frailty syndrome reinforce the implementation of integrated, proactive, and people-centered care models that promote assertive intersectoral strategies, capable of predicting and delaying negative outcomes for older adults, family members/caregivers, and the public system⁸8. Nunes LO, Castanheira ERL, Dias A, Zarili TFT, Sanine PR, Mendonça CS, et al. Importância do gerenciamento local para uma atenção primária à saúde nos moldes de Alma-Ata. Rev. Panam Salud Publica. 2018;42:e175. https://doi.org/10.26633/RPSP.2018.175
https://doi.org/10.26633/RPSP.2018.175... .

The results should be observed based on some limitations. Frailty syndrome is a dynamic and multifactorial condition, with potential transitions between natural regression or worsening. Another issue that limits the study is the lack of a standardized and universal tool for identifying frailty. Similarly, memory bias is another aspect to be considered, since some variables were measured based on the report of the older adults or family members. Also, it should be considered that the development of matrix support activities in medical residency fields defines an unusual situation, which may have influenced the results by greater professional support.

Despite the limitations observed, the study indicates to positive effects for an auxiliary model of MS for the FHS teams in the health care of older adults. The intervention proved to be effective and safe in the awareness of PHC professionals regarding the particularities of the health of older adults. The intervention was also promising in establishing a collective environment that respects the interprofessional relationship in a network. In the current scenario, longevity represents achievements of the contemporary society, but it also exposes profound changes in the epidemiological profile of health conditions, which require bold strategies of individual and collective care¹1. Ministério da Saúde (BR). Diretrizes para o cuidado das pessoas idosas no SUS: proposta de modelo de atenção integral à saúde da pessoa idosa: XXX Congresso Nacional de Secretarias Municipais de Saúde [Internet]. Brasília (DF): Ministério da Saúde; 2014 [cited 2020 Dec11]. Available from: https://bvsms.saude.gov.br/bvs/publicacoes/diretrizes_cuidado_pessoa_idosa_sus.pdf
https://bvsms.saude.gov.br/bvs/publicaco... ,⁴4. Beard JR, Officer A, Carvalho IA, Sadana R, Pot AM, Michel JP, et al. The World report on ageing and health: a policy framework for healthy ageing. Lancet. 2016;387(10033):2145-54. https://doi.org/10.1016/s0140-6736(15)00516-4
https://doi.org/10.1016/s0140-6736(15)00... . Thus, it is expected that the results of this study can support the future implementation of this intervention in public and supplementary services in order to contribute positively to the co-management of comprehensive care for the older adults.

It is also important to highlight that the Brazilian Ministry of Health considered, in the evaluation of the quality of primary care, the standard related to the matrix support received by the family health team as a strategy of permanent education of its workers¹⁷17. Hirdes A. Apoio Matricial em saúde mental: a perspectiva dos especialistas sobre o processo de trabalho. SaúdeDebate. 2018;42(118):656-68. https://doi.org/10.1590/0103-1104201811809
https://doi.org/10.1590/0103-11042018118... ,¹⁸18. Iglesias A, Avellar LZ. Matriciamento em saúde mental: práticas e concepções trazidas por equipes de referência, matriciadores e gestores. CiênSaúde Colet. 2019;24(4):1247-54. https://doi.org/10.1590/1413-81232018244.05362017
https://doi.org/10.1590/1413-81232018244... . It is also important for managers to provide this type of support to teams, in order to better qualify and fix the FHS professionals¹⁷17. Hirdes A. Apoio Matricial em saúde mental: a perspectiva dos especialistas sobre o processo de trabalho. SaúdeDebate. 2018;42(118):656-68. https://doi.org/10.1590/0103-1104201811809
https://doi.org/10.1590/0103-11042018118... ,¹⁹19. Barros JO, Gonçalves RMA, Kaltner RP, Lancman S. Matrix support strategies: the experience of two Family Health Support Centers (NASFs) in São Paulo, Brazil. Ciên Saúde Colet. 2015;20(9):2847-56. https://doi.org/10.1590/1413-81232015209.12232014
https://doi.org/10.1590/1413-81232015209... . In this study, the actions of matrix support in the health of the older adults in PHC reduced the clinical and functional vulnerability of people aged 60 years or older. The intervention by training FHS professionals was also effective in the care of non-frail older adults registered and assisted by these teams.

Therefore, the MS – as pedagogical attribution and horizontal care for health teams – has the potential to contribute to the articulation of care models, with positive results for the health of older adults. Also, it works as a relational instrument, enabling the approximation between the levels of care with the improvement and strengthening of the principles and guidelines of the SUS.

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