ABSTRACT

This review aimed to synthesize and evaluate the production of knowledge about factors significantly associated with frailty in hospitalized elderly. Therefore, the Medical Literature and Retrieval System Online (Medline), Literatura Latino-Americana em Ciências da Saúde (Lilacs) and Índice Bibliográfico Español em Ciencias de la Salud (Ibecs) databases were consulted from 2012 to 2016, whose analysis of twenty articles identified the following factors associated with frailty: increased hospital and post-discharge mortality, prolonged hospitalization, rehospitalization, transfers, advanced age, women and widows, as well as psychosocial, physical and / or functional factors. It is expected that the results of the review will facilitate improvement of the practices and the decision-making of the multiprofessional teams that provide elderly care in the hospital.

KEYWORDS
Frail elderly; Hospitalization; Aging

Introduction

To the term fragility, several meanings are attributed, such as:

Although there is no consensus as to its definition, in the field of geriatrics and gerontology, this term has been used to characterize the most debilitated and vulnerable elderly.

More specifically, fragility is considered a clinical syndrome that increases with age and results in a decline in the physiological reserves of the individual, reducing the efficiency of homeostasis and, consequently, the ability to perform activities of daily living. Therefore, frail elderly individuals present an increased risk for falls, hospitalizations, disability, institutionalization and death (MACEDO; GAZZOLA; NAJAS, 2008MACEDO, C.; GAZZOLA, J. M.; NAJAS, M. Síndrome da fragilidade no idoso: importância da fisioterapia. ABCD: arq. bras. cir. dig, São Paulo, v. 33, n. 3, p. 177-184, 2008.).

In this context, there are measurable characteristics that aim to identify the fragility syndrome in the elderly and that, in turn, are related to the phenotype of the individual, namely: unintentional weight loss, self-report of fatigue, decreased grip strength, reduction of physical activity and slowing gait speed (FRIED ET AL., 2004 APUDLENARDT 2016LENARDT, M. H. et al. Força de preensão manual e atividade física em idosos fragilizados. Rev Esc Enferm USP, São Paulo, v. 50, n. 1, p. 86-92, 2016.). On the other hand, it is also affirmed that fragility is a multidimensional entity, resulting from the interaction of biological, psychological and social factors throughout the life (BERGMAN ET AL., 2004 APUDTEIXEIRA, 2008TEIXEIRA, I. N. D. O. Percepções de profissionais de saúde sobre duas definições de fragilidade no idoso. Ciência & Saúde Coletiva, Rio de Janeiro, v. 13, n. 4, p. 1181-1188, 2008.).

Consequently, in relation to the multidimensionality of the syndrome, studies that indicate socioeconomic factors strongly associated with it are more recent, such as: insufficient income/poverty, low level of schooling, lack of social support, among others (DUARTE, 2009DUARTE, Y. A. O. Indicadores de fragilidade em pessoas idosas visando o estabelecimento de medidas preventivas. Bol Inst Saúde, São Paulo, v. 47, p. 49-52, 2009.). Such factors, combined with the lifestyle of the elderly, presuppose the emergence of chronic diseases, intensifying the use of hospital services, which implies higher costs of treatment, with longer duration and more difficult recovery (SOUZA ., 2014SOUZA, I. C. P. et al. Perfil de pacientes dependentes hospitalizados e cuidadores familiares: conhecimento e preparo para as práticas do cuidado domiciliar. REME, Belo horizonte, v. 18, n. 1, p. 164-172, 2014.).

About 10% to 25% of the elderly population has some clinical aspect predicting fragility, and the fragility syndrome is an etiological factor of disability in the elderly, regardless of comorbidities (BORGES , 2013BORGES, C. L. et al. Avaliação da fragilidade de idosos institucionalizados. Acta Paul Enferm, São Paulo, v. 26, n. 4, p. 318-322, 2013.; CARMO; DRUMMOND; ARANTES, 2011CARMO, L. V.; DRUMMOND, L. P.; ARANTES, P. M. M. Avaliação do nível de fragilidade em idosos participantes de um grupo de convivência. Fisioter Pesqui, São Paulo, v. 18, n. 1, p. 17-22, 2011.). Therefore, due to this causal relation between fragility and the occurrence of adverse health outcomes, it is essential to evaluate their characteristics and prevalence in the brazilian elderly.

For Oliveira (2013)OLIVEIRA, D. R. et al. Prevalência de síndrome da fragilidade em idosos de uma instituição hospitalar. Rev Latino-Am Enferm, v. 21, n. 4, 2013. Disponível em: <http://www.scielo.br/pdf/rlae/v21n4/pt_0104-1169-rlae-21-04-0891.pdf>. Acesso em: 15 ago. 2017.
http://www.scielo.br/pdf/rlae/v21n4/pt_0... , data on fragility in the elderly are still scarce, mainly due to the lack of consensus regarding a definition that can be used in different populations. Thus, additional studies are required to improve the understanding of causal relationships, as well as to identify the manifestation of fragility under some single or multiple forms. The importance of understanding such relationships is to clarify the factors that contribute to each characteristic and how these combines to determine the fragility in individuals (SANTOS, 2008SANTOS, E. G. S. Perfil de fragilidade em idosos comunitários de Belo Horizonte: um estudo transversal. 2008. 95 f. Dissertação (Mestrado em Ciências da Reabilitação) - Universidade Federal de Minas Gerais, Belo Horizonte, 2008.).

Considering the current and relevant theme, this article aims to synthesize and evaluate the scientific knowledge produced about the factors associated with frailty in the hospitalized elderly, an objective that was developed through an integrative review of the literature. In addition, it envisages to awaken in health professionals a greater interest in the development of scientific research that will assist health practices, especially those aimed at minimizing the prevalence of such condition in the population, thus favoring a better quality of life for the elderly.

Methods

This article presents an integrative review of the literature, considered the most comprehensive methodological approach to bibliographic reviews, which allows the inclusion of experimental and non-experimental studies for a complete understanding of the phenomenon or health problem to be studied (SOUZA; SILVA; CARVALHO, 2010SOUZA, M. T.; SILVA, M. D.; CARVALHO, R. Revisão integrativa: o que é e como fazer. Einstein, São Paulo, v. 8, n. 1, p. 102-106, 2010.), which, in the case of the present study, is the frailty in the hospitalized elderly.

For Mendes, Silveira and Galvão (2008)MENDES, K. D. S.; SILVEIRA, R. C. C. P.; GALVÃO, C. M. Revisão integrativa: método de pesquisa para a incorporação de evidências na saúde e na enfermagem. Texto Contexto Enferm, Florianópolis, v. 17, n. 4, p. 758-764, out./dez. 2008., this method of research aims to trace an analysis of the knowledge already constructed in previous research on a given topic and allows the synthesis of several studies already published, allowing the generation of new knowledge, based on the results presented by previous surveys.

About the construction of this review, some steps were taken, namely: 1) choice of the theme and elaboration of the guiding question; 2) choice of the databases used in the research; 3) establishment of inclusion and exclusion criteria; 4) definition of the descriptors; 5) pre-selection of articles; 6) evaluation and selection of the pre-selected studies for inclusion in the review; 7) analysis of results; 8) presentation of the integrative review.

Data collection

Data collection was carried out in the months of november and december 2016, guided by the question: 'What is the production of knowledge about the factors associated with frailty in hospitalized elderly?'. The databases were: Medical Literature and Retrieval System Online (Medline), Latin American Literature in Health Sciences (Lilacs) and Spanish Bibliographical Index on Health Sciences (Ibecs).

The inclusion criteria of the studies were: articles published between the years 2012 and 2016 in the databases mentioned above, in portuguese, english and spanish, with texts available in full and that presented in their results factors significantly associated with frailty in the elderly hospitalized.

On the other hand, studies that included in their sample individuals under the age of 60 and/or hospitalized were excluded, as well as theses, dissertations, congress summaries, annals, editorials, comments and opinions and review articles.

In the evaluation of the articles on the level of evidence, the Hierarchy of Evidence for Intervention Studies (Heis) was used, which classifies the studies into seven levels: I) systematic review or meta-analysis, II) randomized clinical trials, III) clinical trial without randomization, IV) cohort and case-control studies, V) systematic review of descriptive and qualitative studies, VI) single descriptive or qualitative study and VII) opinion of authorities and/or report of specialties committees, being considered for this review only the studies classified in levels II, III, IV and VI (MELNYK , 2010MELNYK, B. M. et al. Evidence-based practice: step by step: the seven steps of evidence-based practice. The American Journal of Nursing, Nova Iorque, v. 110, n. 5, p. 41-47, 2010.).

As a search strategy for the articles, the combination (using the 'and' connector in the search field) of the following Health Sciences Descriptors (DeCS) was used: elderly, frail, and hospital, in portuguese.

The pre-selection of the articles was carried out through the detailed reading of their respective titles and summaries. Therefore, they were withdrawn duplicitously or because they did not meet the pre-established inclusion criteria. Then, the selected articles were read in full, constituting a final sample of 20 articles.

To extract and organize the data, a collection instrument adapted from the Critical Appraisal Skills Programme - Casp, elaborated by the University of Oxford, in 1993, was chosen because of its proposal of objective analysis, its systematic and easy understanding. It consists of 10 items (10 points), covering: 1) objective, 2) methodological adequacy, 3) presentation of theoretical and methodological procedures, 4) sample selection, 5) procedure for data collection, 6) relationship between researcher and researched, 7) consideration of ethical aspects, 8) procedure for data analysis, 9) presentation of results and 10) importance of the research. The studies were classified according to the following scores: 6 to 10 points - good methodological quality and reduced bias, and 5 or fewer points - satisfactory methodological quality, but with increased risk of bias. In this study, it was chosen to use only articles classified above 5 points (LONDON, 2002LONDON. M. K. Primary Care Trust: Critical Appraisal Skills Programme. Londres: Oxford, 2002.).

The analysis of the articles was carried out in a descriptive way, allowing the evaluation of the following research characteristics: authorship, periodical, country of origin, language, research design, year of publication, instrument used and factors associated with fragility.

Analysis and data presentation

The results were organized in a descriptive way in charts and tables, evidencing the relevant aspects of each selected study about the theme on the screen, according to Broome (2006) apudBotelho, Cunha and Macedo (2011)BOTELHO, L. L. R.; CUNHA, C. A. A.; MACEDO, M. O método da revisão integrativa nos estudos organizacionais. Gestão e Sociedade, Belo Horizonte, v. 5 n. 11, p. 121-136, maio/ago. 2011. and respecting the ethical aspects regarding to the citation of the authors of the studies analyzed.

Results and discussion

In this integrative review, 20 studies that strictly met the inclusion criteria previously established were analyzed. The table 1 presents the search results using the descriptors according to the databases (table 1).

Regarding the types of journals in which the articles included in this review were published, eight belonged to journals on geriatrics and gerontology; eight were published in palliative medicine, intensive care and surgery journals; three in nursing journals; and one in a journal focusing on health policy, management and governance.

As for the country of origin of the researches, seven articles came from the european continent (United Kingdom, the Netherlands, Belgium and Poland); five originating in North America (United States); four from South America (Brazil); three from Oceania (Australia) and one from Asia (China). The highest number of researches carried out on the european continent, probably, is because Europe has been presenting, in recent years, a generalized aging, including a significant change in population dynamics. According to Vitoriano (2014VITORIANO, N. S. Envelhecimento da população europeia: perspectivas para contrariar esta tendência. 2014. 34 f. Dissertação (Mestrado em População, Sociedade e Território) - Instituto de Geografia e Ordenamento do Território, Universidade de Lisboa, Lisboa, 2014., P. 3, FREE TRANSLATION), "aging in Europe is a result of the considerable progress made in the economic, social and health fields in terms of services provided to Europeans" together with the various simultaneous population trends that bring low fertility rates and increased average life expectancy.

Regarding the language of the selected articles, only three (of the Lilacs base) were in portuguese, being the other publications of english language. As for the institutions of origin of the studies, only one of the articles was linked to a medical-hospital research organization, while universities and/or hospitals promoted the others.

Consequently, in relation to the research design, most of the studies were cohort type (level IV of evidence) while the others were cross sectional descriptive (level VI of evidence). Among the cohort studies, only one was retrospective observational, based on the analysis of admission data from a tertiary health service. Regarding the time interval considered in this review, studies were found compatible with the inclusion criteria in the last five years, however, most of them were published between 2013 and 2015, which shows a constant updating of the subject addressed.

The chart 1 presents a summary of the characterization of the articles according to the title, authors, database and periodical in which they were published, country of origin of the study, research design and year of publication (chart 1).

Based on cautious reading of selected articles, it was possible to identify the factors significantly associated with frailty in hospitalized elderly. In this sense, chart 2 presents in a concise way, for each study included in the review, the instruments used to evaluate the presence of fragility in the elderly, as well as the results found regarding factors associated with this condition (chart 2).

The Frailty Index, in its several versions, was the most used instrument to evaluate the fragility in the hospital environment, prevailing the model based on the Canadian Study of Health and Aging - CSHA. On this, Rockwood and Mitnitski (2007 APUDSINGH 2012SINGH, I. et al. Predictors of adverse outcomes on an acute geriatric rehabilitation ward. Age Ageing, Londres, v. 41, n. 2, p. 242-246, 2012.) state that valid Fragility Indexes (FIs) can be constructed from different numbers and types of variables that meet certain criteria.

Thus, in the study by Zeng (2015)ZENG, A. et al. Mortality in relation to frailty in patients admitted to a specialized geriatric intensive care unit. J Gerontol A Biol Sci Med Sci, Washington, DC, v. 70, p. 1586-1594, 2015. the FI was calculated by means of a ratio of 52 health deficits, being compared to other prognostic scores in the Intensive Care Unit (ICU), such as the Glasgow Coma Scale and the Karnofsky Scale which, respectively, evaluate the level of consciousness and classify the patient according to the degree of functional deficiencies; Scale of Performance in Palliative Care, among others. Joseph (2014)JOSEPH, B. et al. Superiority of frailty over age in predicting outcomes among geriatric trauma patients: a prospective analysis. JAMA Surg, Chicago, v. 149, n. 8, p. 766-772, 2014. used in their study the FI of 50 variables, which were obtained from the CSHA and included demographic data of the patient, social activity, daily life activities, nutritional status and general state of mood.

Krishnan (2014)KRISHNAN, M. et al. Predicting outcome after hip fracture: using a frailty index to integrate comprehensive geriatric assessment results. Age Ageing, Londres, v. 43, n. 1, p. 122-126, 2014. and Evans (2014)EVANS, S. J. et al. The risk of adverse outcomes in hospitalized older patients in relation to a frailty index based on a comprehensive geriatric assessment. Age Ageing, Londres, v. 43, p. 127-132, 2014. correlated the FI with another geriatric assessment instrument - the Comprehensive Geriatric Assessment, with the first study evaluating 51 deficits in different aspects of health, and the second calculating the FI from 55 variables that focused on cognition, function, mobility, balance, appetite and weight.

Multidimensional Evaluation of the Elderly, another tool used in four studies to support the fragility criteria, is a multidimensional diagnostic process that encompasses five essential evaluation components to determine the medical, psychological, social, environmental and functional capacities of a fragile elderly person, in order to develop a coordinated and integrated plan for the treatment and follow-up of this individual (OO 2013OO, M. T. et al. Assessing frailty in the acute medical admission of elderly patients. J R Coll Physicians Edinb, Endimburgo, v. 43, n. 4, p. 301-308, 2013.).

On the other hand, the Fried's Frailty Criteria, observed in four studies, lists five components or criteria to determine the fragility, namely: unintentional weight loss, decreased muscle strength, exhaustion and/or fatigue, slowness in gaiting speed and low level of physical activity. Elderly with three or more of these items and those with one or two pre-fragile items are classified as fragile. Those with no scoring for fragility are considered robust or non-fragile. (BALDWIN 2014BALDWIN, M. R. et al. The feasibility of measuring frailty to predict disability and mortality in older medical intensive care unit survivors. J. Crit. Care, Orlando, v. 29, n. 3, p. 401-408, 2014.; DENT; HOOGENDIJK, 2014DENT, E.; HOOGENDIJK, E. O. Psychosocial factors modify the association of frailty with adverse outcomes: a prospective study of hospitalised older people. BMC Geriatr, Londres, v. 14, p. 108, 2014.; FRIED , 2001FRIED, L. P. et al. A. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci, v. 56, n. 3, p. 146-156, 2001.).

Three other articles have used the Edmonton Frail Scale, which is composed of nine topics (cognition, functional performance, mood, independence, drug use, social support, nutrition, general health and continence) and which is used by health professionals to detect risk factors for frailty, to determine the level of fragility of the elderly and the main domains that need intervention (ANTUNES , 2015ANTUNES, J. F. S. et al. Avaliação da fragilidade de idosos internados em serviço de emergência de um hospital universitário. Cogitare Enfermagem, Curitiba, v. 20, n. 2, p. 266-273, 2015.; FABRÍCIO-WEHBE , 2009FABRÍCIO-WEHBE, S. C. C. et al. Adaptação cultural e validade da Edmonton Frail Scale - EFS em uma amostra de idosos brasileiros. Rev Latino-Am Enferm, v. 17, n. 6, p. 1043-1049, 2009.; HALEY; WELLS; HOLLAND, 2014HALEY, M. N.; WELLS, Y. D.; HOLLAND, A. E. Relationship between frailty and discharge outcomes in subacute care. Aust Health Rev, Sydney, v. 38, n. 1, p. 25-29, 2014.; STORTI ., 2013STORTI, L. B. et al. Frailty of elderly patients admitted to the medical clinic of an emergency unit at a general tertiary hospital. Texto & Contexto Enferm, Florianópolis, v. 22, n. 2, p. 452-459, 2013.).

Therefore, it was observed that some instruments were used less frequently to evaluate, specifically, the fragility, namely: the Clinical Frailty Scale, the Tilburg Frailty Indicator, the Deficit Index and the Cardiovascular Health Study (CHS) and the Study of Osteoporotic Fracture (SOF). Furthermore, several other existing tools were correlated with the fragility indexes: the Index of Katz (Katz Index of Independence in Activities of Daily Living) and the Lawton's Scale (Lawton's Instrumental Activities of Daily Living), used to evaluate basic life activities (BLAs) and instrumental activities of daily living, respectively; Charlson Index, related to comorbidities; Elderly Mobility Scale; Quality of life questionnaire SF-36 (Health-related quality of life); Hospital Anxiety and Depression Scale; among others.

Regarding the objective of this integrative review, it was noticed that most of the studies correlated the fragility scores and their variables with other instruments capable of evaluating several aspects of the health (physical, mental, emotional and social) of hospitalized elderly in order to identify the factors associated with frailty in these individuals (3, 5, 9, 10, 11, 13, 14, 15, 16, 18, 19). The detailed analysis of the articles allowed the selection of the main factors associated to the fragility shown below:

Factor 1: longer hospitalization time. From the total of 20 articles selected for analysis, 8 referred to the length of stay of the frail elderly in the hospital setting (2, 4, 7, 8, 15, 16, 18, 20). In this context, Tavares (2015)TAVARES, D. M. S. et al. Associação das variáveis socioeconômicas e clínicas com o estado de fragilidade entre idosos hospitalizados. Rev Latino-Am Enferm, Ribeirão Preto, v. 23, n. 6, p. 1121-1129, 2015. and Wallis (2015)WALLIS, S. J. et al. Association of the clinical frailty scale with hospital outcomes. QJM, Oxford, v. 108, n. 12, p. 943-949, 2015. showed that fragile elderly presented a longer average of days of hospitalization in relation to the non-fragile ones, being the time equal or superior to ten days.

In the study by Krishnan (2014)KRISHNAN, M. et al. Predicting outcome after hip fracture: using a frailty index to integrate comprehensive geriatric assessment results. Age Ageing, Londres, v. 43, n. 1, p. 122-126, 2014., carried out with elderly hip fracture victims and suitable for surgery, the individuals of the low fragility group remained hospitalized 21.6 days versus 67.8 days in the high fragility group. Regarding this, the other authors corroborate that the fragility state correlates significantly with the length of hospital stay. Still, as Tavares (2015)TAVARES, D. M. S. et al. Associação das variáveis socioeconômicas e clínicas com o estado de fragilidade entre idosos hospitalizados. Rev Latino-Am Enferm, Ribeirão Preto, v. 23, n. 6, p. 1121-1129, 2015. explain, this fact may be related to the greater number of morbidities, which favors complications and complicates the recovery process.

Factor 2: higher mortality rate. Intra-hospital mortality (3, 4, 7, 11, 15, 16) and hospital post-discharge mortality (1, 8, 9, 12, 14) were outcomes evaluated in most of the studies analyzed. On this, it was verified that higher values in the fragility scores can predict intra-hospital mortality. In the study by Zeng (2015)ZENG, A. et al. Mortality in relation to frailty in patients admitted to a specialized geriatric intensive care unit. J Gerontol A Biol Sci Med Sci, Washington, DC, v. 70, p. 1586-1594, 2015., for example, each 1% increase in FI was associated with an 11% increase in 30-day mortality risk in elderly patients in the ICU. Likewise, as a high endpoint, the frail elderly evaluated also had a higher probability of mortality in three months (HUIJBERTS; BUURMAN; DE ROOIJ, 2016HUIJBERTS, S.; BUURMAN, B. M.; DE ROOIJ, S. E. End-of-life care during and after an acute hospitalization in older patients with cancer, end-stage organ failure, or frailty: a sub-analysis of a prospective cohort study. Palliat Med, Londres, v. 30, n. 1, p. 75-82, 2016.), in six months (JOOSTEN , 2014JOOSTEN, E. et al. Prevalence of frailty and its ability to predict in hospital delirium, falls, and 6-month mortality in hospitalized older patients. BMC Geriatrics, Londres, v. 14, p. 1, 2014.) and in twelve months (DENT; HOOGENDIJK, 2014DENT, E.; HOOGENDIJK, E. O. Psychosocial factors modify the association of frailty with adverse outcomes: a prospective study of hospitalised older people. BMC Geriatr, Londres, v. 14, p. 108, 2014.).

Factor 3: advanced age. The chronological factor was also associated with fragility in four of the studies analyzed (2, 6, 17, 19). Therefore, a higher proportion of frail elderly individuals 80 years of age or older (TAVARES 2015TAVARES, D. M. S. et al. Associação das variáveis socioeconômicas e clínicas com o estado de fragilidade entre idosos hospitalizados. Rev Latino-Am Enferm, Ribeirão Preto, v. 23, n. 6, p. 1121-1129, 2015.) and severe type (STORTI 2013STORTI, L. B. et al. Frailty of elderly patients admitted to the medical clinic of an emergency unit at a general tertiary hospital. Texto & Contexto Enferm, Florianópolis, v. 22, n. 2, p. 452-459, 2013.) were found. In addition, patients older than 85 years were more likely to be fragile than patients aged between 75 to 85 years old (OO 2013OO, M. T. et al. Assessing frailty in the acute medical admission of elderly patients. J R Coll Physicians Edinb, Endimburgo, v. 43, n. 4, p. 301-308, 2013.). Consequently, for Antunes (2015)ANTUNES, J. F. S. et al. Avaliação da fragilidade de idosos internados em serviço de emergência de um hospital universitário. Cogitare Enfermagem, Curitiba, v. 20, n. 2, p. 266-273, 2015., advanced age is associated with a high rate of comorbidities and other deficits, which suggests that older patients score higher on the fragility scales.

Factor 4: readmission. The rates of hospital readmission of the frail elderly are high when compared to non-fragile individuals of the same group; is what was found in three articles (8, 12, 18). In the study by Robinson (2013)ROBINSON, T. N. et al. Simple frailty score predicts postoperative complications across surgical specialties. Am J Surg, Nova Iorque, v. 206, n. 5, p. 544-550, 2013., which associated fragility variables with postoperative complications, the elderly had higher readmission rates within 30 days. The same occurred in the study by Dent and Hoogendijk (2014)DENT, E.; HOOGENDIJK, E. O. Psychosocial factors modify the association of frailty with adverse outcomes: a prospective study of hospitalised older people. BMC Geriatr, Londres, v. 14, p. 108, 2014., in which a greater number of emergency readmissions were observed after one month. Regarding this, it is inferred that the higher rate of readmissions is due to the high number of comorbidities observed in the elderly population, especially fragile. In the study by Perez and Lourenço (2013)PEREZ, M.; LOURENÇO, R. A. Rede FIBRA-RJ: fragilidade e risco de hospitalização em idosos da cidade do Rio de Janeiro, Brasil. Cad. Saúde Pública, Rio de Janeiro, v. 29, n. 7, p. 1381-1391, 2013., the risk of repeated hospitalizations among the elderly in Rio de Janeiro was associated with the presence of chronic diseases, the use of medications, the presence of falls, the poorer health status and the dependence on BLAs.

Factor 5: transfers (4, 7, 8, 17). As a result of the hospitalization, the frail elderly had a higher rate of rehospitalization and admission to Long-Term Institutions (BASIC; SHANLEY, 2015BASIC, D.; SHANLEY, C. Frailty in an older inpatient population: using the clinical frailty scale to predict patient outcomes. J Aging Health, Thousand Oaks v. 27, n. 4, p. 670-685, 2015.; OO ., 2013OO, M. T. et al. Assessing frailty in the acute medical admission of elderly patients. J R Coll Physicians Edinb, Endimburgo, v. 43, n. 4, p. 301-308, 2013.), as well as transference to the geriatric ward (WALLIS 2015WALLIS, S. J. et al. Association of the clinical frailty scale with hospital outcomes. QJM, Oxford, v. 108, n. 12, p. 943-949, 2015.) and high to a higher level of attention (DENT; HOOGENDIJK, 2014DENT, E.; HOOGENDIJK, E. O. Psychosocial factors modify the association of frailty with adverse outcomes: a prospective study of hospitalised older people. BMC Geriatr, Londres, v. 14, p. 108, 2014.). In this context, the worsening of health conditions, especially marked by physical dependence, brings the elderly closer to their relatives, who do not always accept or are able to work as caregivers, increasing the demand for Long Stay Institutions for the Elderly (GALHARDO; MARIOSA; TAKATA, 2010 APUDNÓBREGA , 2015NÓBREGA, I. R. A. P. et al. Fatores associados à depressão em idosos institucionalizados: revisão integrativa. Saúde em Debate, Rio de Janeiro, v. 39, n. 105, p. 536-550, 2015.); a fact that also commonly occurs after hospital discharge.

Other elements associated with fragility found in studies included in this review that deserve attention are: physical and/or functional factors [low mobility (17); reduced functional gain (20); functional dependency (10); disability (11); greater number of falls (17); lower muscle strength (10); preexisting disabilities (1)], psychosocial factors [anxiety (5, 8); delirium (1,17); dementia (6, 17); depression (5, 8); neurological diseases (6); severe cognitive impairment (1); low sense of control (8); decreased well-being (8); lower quality of life (5); poor self-description of health (19); low index of social activities and satisfaction in the domicile or neighborhood (8)], female (19) and widowhood or absence of the companion (2,19).

Conclusions

The present integrative review condensed the scientific productions of the last five years about the subject addressed and allowed to know the factors significantly associated with frailty in the elderly hospitalized because of several causes. In turn, these elements were considered interrelated based on the studies analyzed, regardless of the cause or effect that the fragility brings to the studied population.

Therefore, factors such as age and hospital mortality, for example, may be considered distinct when analyzed from the perspective of causality. This way, it was found that advanced age influences the occurrence of frailty, while higher mortality is related to one of the outcomes experienced by fragile elderly. Other associated factors were: longer hospitalization time, rehospitalization, transfers, female and widowhood, as well as psychosocial, physical and/or functional factors.

In this context, a great variety of elements associated with fragility were perceived, which was justified by the different characteristics of the populations of each country, by the objectives of each research, by the instruments used and by the different samples, which resulted in some divergences of findings between the studies.

The results of this integrative review can help health professionals dealing with the hospitalized elderly both to recognize the signs of fragility and to identify the factors associated with this condition, facilitating the directing of the behaviors and the improvement of their practices, as well as the decision making of the multiprofessional teams, which should consider the total biopsychosocial of the individual.

References

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