ABSTRACT

To investigate the elements of the social network associated with frailty syndrome in older Brazilian adults.

Baseline data from the Brazilian Longitudinal Study of Aging (ELSI-Brazil, 2015–2016) were used. Frailty was defined by the Fried phenotype (unintentional weight loss, exhaustion, weakness, slowness, and low level of physical activity). The social network was assessed using the conceptual model of Berkman and Krishna (social network structure, characteristics of social network ties, social support, and negative social interaction). Potential confounding variables included sociodemographic (age, sex, education, self-reported race, per capita family income, and place of residence) and health characteristics (polypharmacy, multimorbidity, depression, falls, hospitalization, and cognitive function). Analyses were based on multinomial logistic regression.

Among the 8,629 participants, 53.5% were pre-frail individuals and 9.1% were frail individuals. The elements of the social network that were consistently associated with pre-frailty and frailty were the following: characteristics of social network ties, social support, and negative social interaction. A positive association was found for less-than-weekly frequency of virtual contact with sons and daughters (OR = 1.15; 95%CI 1.01–1.33 for pre-frailty and OR = 1.51; 95%CI 1.13–2.02 for frailty) and for loneliness (OR = 1.36; 95%CI 1.19–1.56 for pre-frailty and OR = 1.40; 95%CI 1.12–1.75 for frailty). A negative association was found for social support (help with loans) (OR = 0.75; 95%CI 0.60–0.94 for pre-frailty and OR = 0.54; 95%CI 0.40–0.74 for frailty). However, the perception of criticism was only associated with frailty (OR = 1.35; 95%CI 1.11–1.64).

Social network is an important element for reducing/preventing frailty in older adults. Therefore, public policies and health and social assistance professionals should encompass the older adults’ social network regarding the characteristics of social network ties, social support, and negative social interaction.

DESCRIPTORS:
Social Relations; Social Support; Frailty; Aging

INTRODUCTION

Frailty is a major public health challenge due to its negative impact on individuals’ functionality, which can lead to the need for long-term care and family (re)organization ¹Yuan Y, Lin S, Huang X, Li N, Zheng J, Huang, F. The identification and prediction of frailty based on Bayesian network analysis in a community-dwelling older population. BMC Geriatr. 2022 Nov; 11(847): 1-11. ^{, 2} Dent E, Morley JE, Cruz-Jentoft AJ, Woodhouse L, Rodríguez-Mañas L, Fried LP, et al. Physical Frailty: ICFSR International Clinical Practice Guidelines for Identification and Management. J.Nutr Health Aging. 2019 Nov; 23(9): 771-87. https://doi.org/10.1007/s12603-019-1273-z
https://doi.org/10.1007/s12603-019-1273-... . This syndrome is characterized by increased vulnerability to low homeostatic and adaptive response to minor stressful events ³ Gale CR, Westbury L, Cooper C. Social isolation and loneliness as risk factors for the progression of frailty: The English Longitudinal Study of Ageing. Age Ageing. 2018 May; 47(3): 392-7. https://doi.org/10.1093/ageing/afx188
https://doi.org/10.1093/ageing/afx188... ^{, 4} Jarach CM, Tettamanti M, Nobili A, D’avanzo B. Social isolation and loneliness as related to progression and reversion of frailty in the Survey of Health Aging Retirement in Europe (SHARE). Age Ageing. 2021 Jan; 50(1): 258-62. https://doi.org/10.1093/ageing/afaa168
https://doi.org/10.1093/ageing/afaa168... , and often goes unnoticed by health professionals. From a multidimensional perspective, frailty is influenced by socio-familial vulnerability, whether due to the lack of social support, defined as limited availability of help, or by a scarce social network ³ Gale CR, Westbury L, Cooper C. Social isolation and loneliness as risk factors for the progression of frailty: The English Longitudinal Study of Ageing. Age Ageing. 2018 May; 47(3): 392-7. https://doi.org/10.1093/ageing/afx188
https://doi.org/10.1093/ageing/afx188... ^{, 5} Woo J, Goggins W, Sham A, Ho SC. Social determinants of frailty. Gerontology. 2005 Nov-Dec; 51(6): 402-8. https://doi.org/10.1159/000088705
https://doi.org/10.1159/000088705... , which constitutes a scarce tangle of social relationships established by the individual ⁶Berkman LF, Krishna A. Social Network Epidemiology. In: Berkman LF, Kawachi I, Glymou MM, editors. Social Epidemiology. Oxford: Oxford University Press; 2014. p. 234-89. .

Berkman and Krishna ⁶Berkman LF, Krishna A. Social Network Epidemiology. In: Berkman LF, Kawachi I, Glymou MM, editors. Social Epidemiology. Oxford: Oxford University Press; 2014. p. 234-89. , in line with theorists such as Durkheim and Bowlby, proposed a conceptual model on the impact of the social network on health, based on a macrosocial structure. This model establishes that social networks are embedded in a broader socioeconomic, political, and cultural context that determines the structure itself (size, density, and distance, among others) and the characteristics of the social network ties (frequency of in-person or virtual contacts, reciprocity, and intimacy, among others), providing psychosocial mechanisms that can impact health. Among the mechanisms, social support (positive impact) and negative social interactions (negative impact) stand out.

At an international level, longitudinal data from Mexicans aged 65 or over living in the United States showed that increased emotional social support, defined as demonstrations of care and affection for others, was associated with a lower progression of frailty among those who were moderately frail ⁷ Peek MK, Howrey BT, Ternent RS, Ray LA, Ottenbacher KJ. Social support, stressors, and frailty among older mexican american adults. J Gerontol B Psychol Sci Soc Sci. 2012 Nov; 67(6): 755-64. https://doi.org/10.1093/geronb/gbs081 –
https://doi.org/10.1093/geronb/gbs081... .

Longitudinal and cross-sectional studies reported a positive association between the absence of a partner ⁸ Fhon JRS, Rodrigues RAP, Santos JLF, Diniz MA, Santos EB, VC Almeida, et al. Factors associated with frailty in older adults: A longitudinal study. Rev. Saúde Pública. 2018 Jul; 52: 74. https://doi.org/10.11606/S1518-8787.2018052000497
https://doi.org/10.11606/S1518-8787.2018... ^{, 9} Labra C, Maseda A, Lorenzo-López L, López-López R, Buján A, Rodríguez-Villamil JL, et al. Social factors and quality of life aspects on frailty syndrome in community-dwelling older adults: The VERISAÚDE study. BMC Geriatr. 2018 Mar; 18: 66. https://doi.org/10.1186/s12877-018-0757-8
https://doi.org/10.1186/s12877-018-0757-... and loneliness ³ Gale CR, Westbury L, Cooper C. Social isolation and loneliness as risk factors for the progression of frailty: The English Longitudinal Study of Ageing. Age Ageing. 2018 May; 47(3): 392-7. https://doi.org/10.1093/ageing/afx188
https://doi.org/10.1093/ageing/afx188... and pre-frailty and frailty. Regarding the characteristics of social network ties, the literature indicates that a monthly or lower frequency of contact with friends ¹⁰ Chon D, Lee Y, Kim J, Lee K. The association between frequency of social contact and frailty in older people: Korean frailty and aging cohort study (KFACS). J.Korean Med Sci. 2018 Dec; 33(51): e332. https://doi.org/10.3346/jkms.2018.33.e332
https://doi.org/10.3346/jkms.2018.33.e33... , as well as a social network with few exchanges, are associated with a higher prevalence of frailty ⁵ Woo J, Goggins W, Sham A, Ho SC. Social determinants of frailty. Gerontology. 2005 Nov-Dec; 51(6): 402-8. https://doi.org/10.1159/000088705
https://doi.org/10.1159/000088705... . A Brazilian longitudinal study, conducted with people aged 65 or over, found no association between social support and frailty ¹¹ Fhon JRS, Cabral LMS, Giacomini SBL, Reis NA, Resende MC, Rodrigues RAP. Frailty and sociodemographic and health factors, and social support network in the brazilian elderly: A longitudinal study. Esc Enferm USP. 2021 Dec; 8: 56: e20210192. https://doi.org/10.1590/1980-220X-REEUSP-2021-0192
https://doi.org/10.1590/1980-220X-REEUSP... , but this association was verified in a cross-sectional study ¹² Souza DS, Berlese DB, Cunha GL, Cabral SM, Santos GA. Análise da relação do suporte social e da síndrome de fragilidade em idosos. Psicologia, Saúde & Doença. 2017; 18(2): 420-33. http://dx.doi.org/10.15309/17psd180211
http://dx.doi.org/10.15309/17psd180211... . Nevertheless, the Brazilian studies were not based on a nationally representative sample and have not evaluated the social network.

Several studies have used the term “social network” as a synonym for social support, without distinguishing the possible mechanisms of association with health. Thus, this study is based on the assumption that the social network (social network structure, characteristics of social network ties, and social support) can act as a protective or risk factor (negative social interaction) for frailty. Therefore, the objective of this study is to investigate the elements of the social network associated with frailty in older Brazilian adults.

METHODS

Study design

This is a cross-sectional study, which used baseline data from the Brazilian Longitudinal Study of Aging (ELSI-Brazil, 2015–2016), performed in 2015–2016. ELSI-Brazil is a cohort study conducted on a representative sample of the Brazilian population aged ≥ 50 years. All residents aged 50 years or older in the selected households were eligible to participate, totaling 9,412 participants. More details on the sample selection process can be found in a previous publication ¹³ Lima-Costa MF, Andrade FB, Souza Jr PRB, Neri AL, Duarte YAO, et al. The Brazilian Longitudinal Study of Aging (ELSI-Brazil): Objectives and Design. Am J Epidemiol. 2018 Jul; 187(7): 1345-53. http://dx.doi.org/10.1093/aje/kwx387
http://dx.doi.org/10.1093/aje/kwx387... . ELSI-Brazil was approved by the Ethics Committee of the Fundação Oswaldo Cruz, Minas Gerais, Brazil (number: 34649814.3.0000.5091). All participants signed the Informed Consent Form.

Dependent variable

Frailty was defined by the phenotype of Fried et al. ¹⁴ 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 Mar; 56(3): M146-56. http://dx.doi.org/10.1093/gerona/56.3.m146
http://dx.doi.org/10.1093/gerona/56.3.m1... , according to the number of positive criteria: three or more as “frail,” one or two as “pre-frail,” and none as “non-frail.” The criteria were: (1) Weight loss: self-reported weight loss of 4.5 kg or more in the last three months, without any intention/diet; (2) Exhaustion: frequencies greater than 3-4 days for any of the following questions from the Center for Epidemiological Studies Depression Scale (CES-D) ¹⁵ Radloff LS. The CES-D Scale: A Self-Report Depression Scale for Research in the General Population. Appl Psychol Meas. 1977 Jun; 1(3): 385-401. https://doi.org/10.1177/014662167700100306
https://doi.org/10.1177/0146621677001003... . “Did you feel that you couldn’t get going?”; “Did you feel that everything you do is an effort?”; (3) Weakness: handgrip strength in the lowest quintile, after adjusting for sex and body mass index (BMI) quartiles, and those who were bedridden or unable to perform the test ¹⁶ Andrade JM, Duarte YAO, Alves LC, Andrade FCD, Souza Junior PRB, Lima-Costa MF, et al. Perfil da fragilidade em adultos mais velhos brasileiros: ELSI-Brasil. Rev Saúde Pública. 2018 Jan; 52(2): 1s-17s. https://doi.org/10.11606/S1518-8787.2018052000616
https://doi.org/10.11606/S1518-8787.2018... . Strength was assessed in three attempts, using a hand dynamometer on the dominant upper limb and considering the best performance; (4) Slowness: quintile of longest time spent walking 3 m in the usual way, stratified by sex and height, and those who were bedridden or unable to perform the test ¹⁶ Andrade JM, Duarte YAO, Alves LC, Andrade FCD, Souza Junior PRB, Lima-Costa MF, et al. Perfil da fragilidade em adultos mais velhos brasileiros: ELSI-Brasil. Rev Saúde Pública. 2018 Jan; 52(2): 1s-17s. https://doi.org/10.11606/S1518-8787.2018052000616
https://doi.org/10.11606/S1518-8787.2018... ; and (5) Low physical activity: lowest quintile of energy expenditure measured in kilocalories (kcals) per week, stratified by sex ¹⁶ Andrade JM, Duarte YAO, Alves LC, Andrade FCD, Souza Junior PRB, Lima-Costa MF, et al. Perfil da fragilidade em adultos mais velhos brasileiros: ELSI-Brasil. Rev Saúde Pública. 2018 Jan; 52(2): 1s-17s. https://doi.org/10.11606/S1518-8787.2018052000616
https://doi.org/10.11606/S1518-8787.2018... . The kcals spent in the last week on activities carried out at work, going from one place to another, leisure, sports, practicing exercise or performing household chores were counted considering the intensity (light, moderate, and vigorous) and time (minutes/hours), based on the Short Form of the International Physical Activity Questionnaire (IPAQ) ¹⁷Matsudo S, Araújo T, Matsudo V, Andrade D, Andrade E, Oliveira LC, Braggion G. Questionário Internacional de Atividade Física (IPAQ): Estudo de Validade e Reprodutibilidade no Brasil. Revista brasileira de atividade física & saúde. 2012 Sep; 6(2): 5-18. .

Independent variables

The independent variables were those related to the elements of the social network, based on the conceptual model of Berkman and Krishna ⁶Berkman LF, Krishna A. Social Network Epidemiology. In: Berkman LF, Kawachi I, Glymou MM, editors. Social Epidemiology. Oxford: Oxford University Press; 2014. p. 234-89. on the impact of the social network on health. The elements selected for this study were: social network structure, characteristics of the social network ties, social support, and negative social interaction.

Social network structure

According to the conceptual model of Berkman and Krishna ⁶Berkman LF, Krishna A. Social Network Epidemiology. In: Berkman LF, Kawachi I, Glymou MM, editors. Social Epidemiology. Oxford: Oxford University Press; 2014. p. 234-89. , the social network structure can be assessed by size, density, and distance, among others. This study focused on the social network size and the type of family living arrangement.

The social network size was assessed by adding the total number of people who are part of the participant’s social network, considering children, grandchildren or great-grandchildren, and living siblings, based on three questions about the number of (1) living children, (2) living grandchildren or great-grandchildren, and (3) living siblings.

Friends and/or neighbors were not included in the social network size, since the number of people for the ties in question is not included in the ELSI-Brazil baseline. The total social network size was used as a continuous variable and, due to its distribution, was truncated to 50 people. The family living arrangement was assessed by self-report, considering living alone, living with a partner, or other arrangements.

Characteristics of social network ties

According to the conceptual model of Berkman and Krishna ⁶Berkman LF, Krishna A. Social Network Epidemiology. In: Berkman LF, Kawachi I, Glymou MM, editors. Social Epidemiology. Oxford: Oxford University Press; 2014. p. 234-89. , the characteristics of social network ties can be assessed based on the frequency of contacts (in-person or virtual), reciprocity, multiplicity, duration, and intimacy. This study focused on the frequency of contacts.

The frequency of contacts with the social network was defined separately for in-person and virtual contacts, considering only individuals who did not live with the participant.

“In-person contact” was defined as personal encounters, and “virtual contact” was defined as conversations by telephone, Skype, WhatsApp, Facebook, with children, relatives, or friends. The frequency of contacts was assessed by self-report, according to three response categories: at least once/week, less than once/week, or no link related to the category analyzed (children, relatives, or friends).

Social support

Instrumental social support was assessed by self-report on the availability of help: with the house (yes or no); with going shopping, paying bills, or going to the bank (yes or no), in case of illness; and with loans, including money or objects (yes or no). Emotional social support was assessed by self-report on the availability of a person to confide in (yes or no).

Negative social interaction

Assessed based on the individual’s perception of loneliness, criticism, and excessive care. Loneliness, assessed based on the perception of feeling alone or lonely, by a single question: “How often do you feel alone (lonely)?” (hardly ever, some of the time, often). Perception of criticism assessed by the question: “Do you think that people make too many demands from or criticisms of you?” (never, sometimes, or always). Perception of excessive care, by the question: “Do you feel bothered because you think that people try to help you more than you think you need?” (never, sometimes, or always) For the three variables, the response categories “sometimes” and “always” were grouped together.

Potential confounding variables

Sociodemographic and health-related characteristics were considered potential confounding variables. The sociodemographic variables were: age (50–59; 60–69; 70–79; ≥ 80 years); sex (female or male); education, in completed years (never studied, 1–4 years, 5–8 years, ≥ 9 years); self-reported race (White, Black, Mixed-race or other); per capita family income, in tertiles [lower up to R$ 558.70), middle (from R$ 558.71 to R$ 1,000.00) and upper (≥ R$ 1,000.01)] tertiles; and place of residence (urban or rural). The health-related characteristics were: health-perception (very good/good, fair, or poor/very poor); polypharmacy, considering the regular use of five or more medications prescribed by a doctor ¹⁸ Seixas BV, Freitas GR. Polypharmacy among older Brazilians: prevalence, factors associated, and sociodemographic disparities (ELSI-Brazil). Pharmacy Practice (Granada). 2021 Jan-Mar; 19(1): 1-10. https://dx.doi.org/10.18549/pharmpract.2021.1.2168
https://dx.doi.org/10.18549/pharmpract.2... and used in the last two weeks (yes or no); multimorbidity ¹⁹ Nunes BP, Souza ASS, Nogueira J, Andrade FB, Thumé E, Teixeira DSC, et al. Multimorbidade e população em risco para COVID-19 grave no Estudo Longitudinal da Saúde dos Idosos Brasileiros. Cad Saúde Pública. 2020; 36(12): e00129620. https://doi.org/10.1590/0102-311X00129620
https://doi.org/10.1590/0102-311X0012962... (yes or no); medical diagnosis of depression (yes or no); self-report on falls in the last 12 months (yes or no); hospitalization in the last 12 months, considering hospitalizations for at least 24 hours (yes or no), and cognitive function.

Multimorbidity was considered the presence of two or more chronic conditions, including cardiovascular diseases (arterial hypertension, stroke, acute myocardial infarction, angina, and heart failure), chronic kidney disease, chronic neurological disease (Alzheimer’s disease and Parkinson’s disease), chronic respiratory disease (emphysema, chronic obstructive pulmonary disease, and bronchitis), diabetes, arthritis, asthma, cancer, and obesity. All chronic conditions were obtained by self-report on a history of medical diagnosis, except obesity, which was characterized based on the objective measurement of weight and height from the BMI calculation (≥ 30 kg/m2 for those under 60 years old, and ≥ 27 kg/m2 for those aged 60 or over) ¹⁹ Nunes BP, Souza ASS, Nogueira J, Andrade FB, Thumé E, Teixeira DSC, et al. Multimorbidade e população em risco para COVID-19 grave no Estudo Longitudinal da Saúde dos Idosos Brasileiros. Cad Saúde Pública. 2020; 36(12): e00129620. https://doi.org/10.1590/0102-311X00129620
https://doi.org/10.1590/0102-311X0012962... . Cognitive function was assessed based on language and executive function, using the one-minute semantic verbal fluency test, considering the total number of animals mentioned ²⁰ Castro-Costa E, Lima-Costa MF, Andrade FB, Souza Junior PRB, Ferri CP. Cognitive function among older adults. Rev Saúde Pública. 2019 Jan; 52(2). https://doi.org/10.11606/S1518-8787.2018052000629
https://doi.org/10.11606/S1518-8787.2018... .

Statistical analysis

Frequency distributions were calculated for categorical variables, observing differences using Pearson’s chi-square test, with Rao-Scott correction. For continuous variables, the mean and 95% confidence interval (95%CI) were calculated. Differences between frailty categories were assessed using the adjusted Wald test.

For group and adjusted analyses, multinomial logistic regression models were used to estimate odds ratios (OR) and their respective 95%CI of the association between social network and frailty. The analyses were performed separately by blocks of social network variables and, subsequently, adjusted for all potential confounding variables, as follows: (1) social network structure; (2) characteristics of social network ties (in-person contact); (3) characteristics of social network ties (virtual contact); (4) social support; and (5) negative social interaction. The multicollinearity test was used to test the correlation between the variables included in the multivariate models. The variables related to the characteristics of social network ties (frequency of contacts) associated with frailty were plotted in a figure. All analyses were performed using Stata/SE® software (StataCorp., CollegeStation, United States), version 14.2, considering the sample design and participants’ weights.

RESULTS

With regard to the 9,412 participants in the ELSI-Brazil baseline, 8,629 (91.7%) had complete information about frailty classification and were included in the study. The mean age was 62.2 years (95%CI 61.4–63.1). Among the participants, 53.5% (95%CI 51.8–55.1) were pre-frail individuals and 9.1% (95%CI 8.0–10.2) were frail individuals. Participants’ characteristics according to frailty are described in Table 1 . Among the frail individuals, 50.8% were under 70 years of age, 44.8% had up to four years of schooling, and 34.0% had poor/very poor self-perceived health. All characteristics showed significant differences between the frailty categories, except for place of residence.

The distribution of social network elements according to frailty is described in Table 2 . The participants had a social network of 13 people on average (95%CI 12.4–13.8), and approximately 65% ​​lived with a partner. Among the frail individuals, the highlights are the largest average social network size (16.1; 95%CI 14.8–17.4) and the highest level of frequency of contacts, less than once/week, in-person (67.9%) and virtual (63.0%) with relatives. It is also possible to observe that, in this group, there is lower prevalence of instrumental social support (availability of help with loans) and emotional support (availability of someone to confide in), and higher prevalence of loneliness (58.8%) and perception of excessive care (39%).

The results of the multinomial logistic regression are described in Table 3 . As multicollinearity was not evidenced (Variance Inflation Factor [VIF] < 2), all confounding variables were maintained in the adjusted models. Considering the adjusted models, the chance of pre-frailty was higher among those who reported frequency of virtual contact with children (OR = 1.15; 95%CI 1.01–1.33) and relatives (OR = 1.18; 95%CI 1.05–1.34) less than once/week, had no relatives or friends, and reported feeling lonely some of the time/often (OR = 1.36; 95%CI 1.19–1.56). We also observed that the chance of pre-frailty was lower among those who reported availability of help with the house (OR = 0.66; 95%CI 0.46-0.94) and with loans (OR = 0.75; 95%CI 0.60–0.94).

The chance of frailty was higher among those who reported frequency of virtual contact with children (OR = 1.51; 95%CI 1.13–2.02) less than once/week, had no children or relatives, reported loneliness (OR = 1.40; 95%CI 1.12–1.75) and perception of criticism (OR = 1.35; 95%CI 1.11–1.64) sometimes/always. On the other hand, lower odds of frailty were found for availability of help with loans (OR = 0.54; 95%CI 0.40–0.74).

According to Figure 1 , the predicted probability of frailty increases as age increases in all groups of frequency of virtual contacts. However, it can be seen in Figure 1 (A) that the probability is lower in the group with the highest frequency of virtual contacts with children, reaching 36.1% of individuals in this group at 100 years of age; in the lowest frequency of virtual contacts, it reaches around 42% of individuals at the same age. A similar pattern is seen in Figure 1 (B), for frequency of virtual contacts with relatives, with a higher probability of frailty among the group that has no relatives (46.2%) at 100 years of age.

DISCUSSION

This study showed that the elements of the social network that were consistently associated with pre-frailty and frailty were the characteristics of social network ties (low frequency of virtual contacts with children and no relatives), social support (unavailability of help with loans), and negative social interaction (feeling lonely). Other elements were associated only with frailty: perception of criticism and no children.

In this study, pre-frailty and frailty were positively associated with not having relatives and the non-weekly frequency of virtual contact with children. Although older adults may have difficulty using equipment that allows virtual contact, it is possible that sons and daughters have greater ease with virtual contact than in-person contact due to their routines with their own children, work, and studies ²¹ Torres JL, Braga LS, Moreira BS, Castro CMS, Vaz CT, Andrade ACS, et al. Loneliness and social disconnectedness in the time of pandemic period among Brazilians: evidence from the ELSI COVID-19 initiative. Aging Ment Health. 2022 May; 26(5): 898-904. https://doi.org/10.1080/13607863.2021.1913479
https://doi.org/10.1080/13607863.2021.19... . Among Korean individuals in the 70-84 age group, there was a positive association between the frequency of monthly or rare contact with friends and pre-frailty and frailty ¹⁰ Chon D, Lee Y, Kim J, Lee K. The association between frequency of social contact and frailty in older people: Korean frailty and aging cohort study (KFACS). J.Korean Med Sci. 2018 Dec; 33(51): e332. https://doi.org/10.3346/jkms.2018.33.e332
https://doi.org/10.3346/jkms.2018.33.e33... . In Brazil, similar results were found for less than three monthly meetings with friends and disability ²² Torres JL, Dias RC, Ferreira FR, Macinko J, Lima-Costa MF. Functional performance and social relations among the elderly in Greater Metropolitan Belo Horizonte, Minas Gerais State, Brazil: a population-based epidemiological study. Cad Saúde Pública. 2014 May; 30(5): 1018-28. https://doi.org/10.1590/0102-311X00102013
https://doi.org/10.1590/0102-311X0010201... . However, none of the mentioned studies differentiated virtual contacts from in-person contacts.

Regarding the negative association of instrumental social support with pre-frailty and frailty, the findings of this study diverged from those reported in the cities of Natal (state of Rio Grande do Norte) ²³ Amaral FLJS, Guerra RO, Nascimento AFF, Maciel ÁCC. Apoio social e síndrome da fragilidade em idosos residentes na comunidade. Cien Saúde Colet. 2013 Jun; 18(6): 1835-46. https://doi.org/10.1590/S1413-81232013000600034
https://doi.org/10.1590/S1413-8123201300... and Ribeirão Preto (state of São Paulo) ¹¹ Fhon JRS, Cabral LMS, Giacomini SBL, Reis NA, Resende MC, Rodrigues RAP. Frailty and sociodemographic and health factors, and social support network in the brazilian elderly: A longitudinal study. Esc Enferm USP. 2021 Dec; 8: 56: e20210192. https://doi.org/10.1590/1980-220X-REEUSP-2021-0192
https://doi.org/10.1590/1980-220X-REEUSP... , where social support was not associated with frailty. Relying on instrumental social support, especially regarding financial issues, can be a factor for the older adult not worrying about the future, since financial pressure acts as a chronic stressor and increases the risk of frailty ⁷ Peek MK, Howrey BT, Ternent RS, Ray LA, Ottenbacher KJ. Social support, stressors, and frailty among older mexican american adults. J Gerontol B Psychol Sci Soc Sci. 2012 Nov; 67(6): 755-64. https://doi.org/10.1093/geronb/gbs081 –
https://doi.org/10.1093/geronb/gbs081... .

More than 90% of participants reported availability of instrumental and emotional social support, except for pre-frail and frail individuals in relation to instrumental social support (loans of money and/or objects). Studies conducted in Brazilian cities have also shown a high level of availability of social support, ranging from 91.4% in Belo Horizonte (state of Minas Gerais) ²² Torres JL, Dias RC, Ferreira FR, Macinko J, Lima-Costa MF. Functional performance and social relations among the elderly in Greater Metropolitan Belo Horizonte, Minas Gerais State, Brazil: a population-based epidemiological study. Cad Saúde Pública. 2014 May; 30(5): 1018-28. https://doi.org/10.1590/0102-311X00102013
https://doi.org/10.1590/0102-311X0010201... to 98.8% in Ivoti (state of Rio Grande do Sul) ¹² Souza DS, Berlese DB, Cunha GL, Cabral SM, Santos GA. Análise da relação do suporte social e da síndrome de fragilidade em idosos. Psicologia, Saúde & Doença. 2017; 18(2): 420-33. http://dx.doi.org/10.15309/17psd180211
http://dx.doi.org/10.15309/17psd180211... .

However, the idea that social support will be available in case of need may or may not correspond to the actual provision of support when needed ⁶Berkman LF, Krishna A. Social Network Epidemiology. In: Berkman LF, Kawachi I, Glymou MM, editors. Social Epidemiology. Oxford: Oxford University Press; 2014. p. 234-89. . In this sense, relying solely on informal social support provided by friends, neighbors, and family may not be the most appropriate option ²⁴ Brito TRP, Nunes DP, Corona LP, Alexandre TS, Duarte YAO. Low supply of social support as risk factor for mortality in the older adults. Arch Gerontol Geriatr. 2017 Nov; 73: 77-81. https://doi.org/10.1016/j.archger.2017.07.016
https://doi.org/10.1016/j.archger.2017.0... . A longitudinal study conducted with Dutch individuals aged 65 or over found no decrease in emotional and instrumental social support provided among the frail during a three-year follow-up ²⁵ Hoogendijk EO, Suanet B, Dent E, Deeg DJH, Aartsen MJ. Adverse effects of frailty on social functioning in older adults: Results from the Longitudinal Aging Study Amsterdam. Maturitas. 2016 Jan; 83: P45-50. https://doi.org/10.1016/j.maturitas.2015.09.002
https://doi.org/10.1016/j.maturitas.2015... . Nevertheless, a longitudinal study conducted in Ribeirão Preto (state of São Paulo) showed that, over the course of 10 years, there was a reduction in the average amount of social support provided by family, friends, and health services to older adults ¹¹ Fhon JRS, Cabral LMS, Giacomini SBL, Reis NA, Resende MC, Rodrigues RAP. Frailty and sociodemographic and health factors, and social support network in the brazilian elderly: A longitudinal study. Esc Enferm USP. 2021 Dec; 8: 56: e20210192. https://doi.org/10.1590/1980-220X-REEUSP-2021-0192
https://doi.org/10.1590/1980-220X-REEUSP... .

Considering negative social interaction, loneliness was positively associated with pre-frailty and frailty, while the individual’s perception of criticism was only associated with frailty. Those who reported loneliness had 36% and 40% greater chance of pre-frailty and frailty, respectively. The association between loneliness and pre-frailty and frailty was also found in longitudinal studies, in a bidirectional manner: loneliness as a risk factor for frailty ³ Gale CR, Westbury L, Cooper C. Social isolation and loneliness as risk factors for the progression of frailty: The English Longitudinal Study of Ageing. Age Ageing. 2018 May; 47(3): 392-7. https://doi.org/10.1093/ageing/afx188
https://doi.org/10.1093/ageing/afx188... ^{, 4} Jarach CM, Tettamanti M, Nobili A, D’avanzo B. Social isolation and loneliness as related to progression and reversion of frailty in the Survey of Health Aging Retirement in Europe (SHARE). Age Ageing. 2021 Jan; 50(1): 258-62. https://doi.org/10.1093/ageing/afaa168
https://doi.org/10.1093/ageing/afaa168... and frailty as a risk factor for loneliness ²⁶ Hoogendijk EO, Smit AP, van Dam C, Schuster NA, Breij S, Holwerda TJ, et al. Frailty Combined with Loneliness or Social Isolation: an Elevated Risk for Mortality in Later Life. J Am Geriatr Soc. 2020 Nov; 68(11): 2587-93. https://doi.org/10.1111/jgs.16716
https://doi.org/10.1111/jgs.16716... . Various international longitudinal studies point to the scarcity of social contacts among people aged 65 or over. A study with Dutch people found an increase in loneliness among frail people over three years ²⁵ Hoogendijk EO, Suanet B, Dent E, Deeg DJH, Aartsen MJ. Adverse effects of frailty on social functioning in older adults: Results from the Longitudinal Aging Study Amsterdam. Maturitas. 2016 Jan; 83: P45-50. https://doi.org/10.1016/j.maturitas.2015.09.002
https://doi.org/10.1016/j.maturitas.2015... ; in another study with Mexicans living in the United States, 16% reported that they “almost never” had anyone to talk to, tell or discuss their problems ⁷ Peek MK, Howrey BT, Ternent RS, Ray LA, Ottenbacher KJ. Social support, stressors, and frailty among older mexican american adults. J Gerontol B Psychol Sci Soc Sci. 2012 Nov; 67(6): 755-64. https://doi.org/10.1093/geronb/gbs081 –
https://doi.org/10.1093/geronb/gbs081... . A cross-sectional study in Korea indicates that 11% to 15% of individuals had no one to talk to or count on ²⁷Jeon GS, Jang SN, Park S. Social Support, Social Network, and Frailty in Korean Elderly. Journal of the Korean Geriatrics Society. 2012; 16: 84-94. .

The need to connect is a human characteristic and is directly associated with bonds and feelings of companionship ²⁸ Santini ZI, Jose PE, Cornwell EY, Koyanagi A, Nielsen L, Hinrichsen C, et al. Social disconnectedness, perceived isolation, and symptoms of depression and anxiety among older Americans (NSHAP): a longitudinal mediation analysis. Lancet Public Health. 2020 Jan; 5(1): e62-70. https://doi.org/10.1016/S2468-2667(19)30230-0
https://doi.org/10.1016/S2468-2667(19)30... , so that not having children, relatives, or friends can generate feelings of loneliness. It is even possible that one of the causes of persistent negative social interactions experienced by older adults is the mismatch between the need for social support they require and the capacity of members of their social network to provide it, which would produce tensions ¹Yuan Y, Lin S, Huang X, Li N, Zheng J, Huang, F. The identification and prediction of frailty based on Bayesian network analysis in a community-dwelling older population. BMC Geriatr. 2022 Nov; 11(847): 1-11. . Therefore, assessing feelings of loneliness and the quality of relationships established by older adults have to be a priority for health and social assistance services in view of the risks of frailty and future disabilities ⁴ Jarach CM, Tettamanti M, Nobili A, D’avanzo B. Social isolation and loneliness as related to progression and reversion of frailty in the Survey of Health Aging Retirement in Europe (SHARE). Age Ageing. 2021 Jan; 50(1): 258-62. https://doi.org/10.1093/ageing/afaa168
https://doi.org/10.1093/ageing/afaa168... .

According to the conceptual model of Berkman and Krishna ⁶Berkman LF, Krishna A. Social Network Epidemiology. In: Berkman LF, Kawachi I, Glymou MM, editors. Social Epidemiology. Oxford: Oxford University Press; 2014. p. 234-89. , the State is part of the macrosocial structure of individuals’ social networks. Therefore, it is its role to promote actions that expand social support, care, and assistance for these individuals and their families ²⁴ Brito TRP, Nunes DP, Corona LP, Alexandre TS, Duarte YAO. Low supply of social support as risk factor for mortality in the older adults. Arch Gerontol Geriatr. 2017 Nov; 73: 77-81. https://doi.org/10.1016/j.archger.2017.07.016
https://doi.org/10.1016/j.archger.2017.0... . Neumann and Albert ²⁹ Neumann LTV, Albert SM. Aging in Brazil. Gerontologist. 2018 Jul; 58(4): 611-7. https://doi.org/10.1093/geront/gny019
https://doi.org/10.1093/geront/gny019... highlight that Brazil should offer long-term care policies, given the growing number of older adults with disabilities and the reduced availability of family care. The authors emphasize the need for the State to recognize the value of care provided by families, including providing them with financial support.

A successful experience of instrumental and emotional social support is the Maior Cuidado Program in Belo Horizonte (state of Minas Gerais), which supports vulnerable families in providing home care to older people who need help to perform basic activities of daily living, preventing situations of risk, exclusion, social isolation, and family overload, in an inter-sectoral manner ³⁰ Lloyd-Sherlock P, Giacomin K, Sempé L. The effects of an innovative integrated care intervention in Brazil on local health service use by dependent older people. BMC Health Serv Res. 2022 Feb; 22(1): 176. https://doi.org/10.1186/s12913-022-07552-y .
https://doi.org/10.1186/s12913-022-07552... .

Intervention in the individuals’ social network can act as a factor in modifying frailty, in addition to the interventions already described in the literature such as: physical activity, protein/calorie supplementation in cases of malnutrition and weight loss, and management of sarcopenia ² Dent E, Morley JE, Cruz-Jentoft AJ, Woodhouse L, Rodríguez-Mañas L, Fried LP, et al. Physical Frailty: ICFSR International Clinical Practice Guidelines for Identification and Management. J.Nutr Health Aging. 2019 Nov; 23(9): 771-87. https://doi.org/10.1007/s12603-019-1273-z
https://doi.org/10.1007/s12603-019-1273-... . The implementation by the government of Community Groups, Day Centers, Homes, Community Housing, and programs such as Maior Cuidado are possible interventions in the individuals’ social network, which provide social support with an impact on the health and well-being of individuals and their families.

This study has strengths and weaknesses. A strong point is its pioneering nature in analyzing various elements of the social network in a nationally representative sample. Nonetheless, its cross-sectional nature does not allow for establishing causal relationships between the social network and frailty. In addition, all social network variables included reflect the individuals’ perception, which does not always indicate reality. In addition, the instrumental social support questions included reflected an expectation of receiving help from other people in the event of a possible health need, which may not be consistent with the actual availability of help. Another limitation was the lack of information about the number of friends and neighbors to measure the social network size, which may have explained the higher average social network size among frail individuals, compared to non-frail and pre-frail individuals.

Thus, future studies could objectively measure the availability of support offered by social network members or count the members of the social network in relation to strong or weak ties regarding social support provision. It is worth noting that ELSI-Brazil is a prospective cohort study, and future analyses of the same elements of the social network from a longitudinal perspective may clarify the temporality of the associations found.

Finally, frailty is reinforced in its multidimensional perspective, so that interventions in the social network have the potential to reduce and prevent frailty. Public policymakers, authorities, and health and social assistance professionals should cover the older adults’ social network, in relation to the characteristics of social network ties, social support, and negative social interaction. Implementing the services already guaranteed by law needs to be an immediate action by the State as a way of supporting the family in care, expanding the possibilities of social support provided, and reducing feelings of loneliness.

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