Anemia and the frailty syndrome amongst the elderly living in the community: a systematic review

A systematic literature review of articles from the MEDLINE and LILACS databases published in English, Spanish and Portuguese over the last ten years was carried out. Articles were included in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

Results:

The search identified 193 studies. After deleting duplicated articles and applying the exclusion criteria only seven articles remained. Three articles used standardized criteria to define frailty, whereas four evaluated functional capacity as a synonym for the frailty syndrome.

Conclusion:

Anemia was related to a worsening of functional capacity and to the presence of the frailty syndrome in elderly persons living in the community. However, the risk of bias in the studies was high in relation to the selection of the criteria and instruments used to assess and define frailty.

Keywords:
Anemia; Frayl Elderly; Sarcopenia; Muscle Strength; Wallking Speed.

Authorship

Elisa Priscila Sousa de Assis

Instituto de Ensino e Pesquisa da Santa Casa de Belo Horizonte, Programa de Pós-graduação Stricto Sensu em Medicina e Biomedicina, Laboratório de Epidemiologia. Belo Horizonte, Minas Gerais, Brasil.Instituto de Ensino e Pesquisa da Santa Casa de Belo HorizonteBrasilBelo Horizonte, Minas Gerais, Brasil Instituto de Ensino e Pesquisa da Santa Casa de Belo Horizonte, Programa de Pós-graduação Stricto Sensu em Medicina e Biomedicina, Laboratório de Epidemiologia. Belo Horizonte, Minas Gerais, Brasil.

Fundação Hospitalar do Estado de Minas Gerais (FHEMIG), Hospital Regional de Barbacena Dr. José Américo, Fisioterapia Respiratória. Barbacena, Minas Gerais, Brasil. Fundação Hospitalar do Estado de Minas GeraisBrasilBarbacena, Minas Gerais, Brasil Fundação Hospitalar do Estado de Minas Gerais (FHEMIG), Hospital Regional de Barbacena Dr. José Américo, Fisioterapia Respiratória. Barbacena, Minas Gerais, Brasil.

Barbara Gazolla de Macêdo

Instituto da Previdência dos Servidores do Estado de Minas Gerais (IPSEMG), Departamento de Fisioterapia. Belo Horizonte, Minas Gerais, Brasil.Instituto da Previdência dos Servidores do Estado de Minas GeraisBrasilBelo Horizonte, Minas Gerais, Brasil Instituto da Previdência dos Servidores do Estado de Minas Gerais (IPSEMG), Departamento de Fisioterapia. Belo Horizonte, Minas Gerais, Brasil.

Hanna Sette Camara de Oliveira

Poliana de Paula Dias Rezende

Carlos Maurício Figueiredo Antunes

Correspondence Barbara Gazolla de Macêdo barbaragazolla@terra.com.br

SCIMAGO INSTITUTIONS RANKINGS

Figures | Tables

Figures (1)
Tables (4)

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Figure 1
Flowchart of phases of review in accordance with PRISMA criteria. Belo Horizonte, Minas Gerais, 2017.

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Chart 1
Adaptation of Newcastle-Ottawa Scale for evaluation of quality of studies. Belo Horizonte, Minas Gerais, 2017.

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Chart 2
Anemia and Frailty Syndrome (defined criteria). Belo Horizonte, Minas Gerais, 2017.

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Chart 3
Anemia and functional capacity. Belo Horizonte, Minas Gerais, 2017.

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Chart 4.Assessment
of bias risk according to the adaptation of the Newcastle-Ottawa Scale. Belo Horizonte, Minas Gerais, 2017.

Figure 1 Flowchart of phases of review in accordance with PRISMA criteria. Belo Horizonte, Minas Gerais, 2017.

Chart 1 Adaptation of Newcastle-Ottawa Scale for evaluation of quality of studies. Belo Horizonte, Minas Gerais, 2017.

Exposure	a) Secure record + primary measures * (low risk of bias)
Obtaining the independent variables	b) Structured interview + primary measures, without knowledge of the outcome * (low risk of bias)
	c) Interview with knowledge of the outcome (high risk of bias)
	d) Non-secure sources and self-assessment (high risk of bias)
	e) Does not describe clearly (uncertain risk of bias)
Outcome
Is the assessment of frailty adequate?	a) Yes, (low risk of bias)
	b) Yes, according to Fried et al. with some modifications (2 or 1 components) (uncertain risk of bias)
	c) Yes, according to Fried et al., with many modifications (3 or more components) (high risk of bias)
	d) No, describes as functional capacity (high risk of bias)
Sample representativeness	a) Representative of the local population * (low risk of bias)
	b) Possibility of selection bias (high risk of bias)
	c) Does not clearly describe (uncertain risk of bias)
Selection of participants	a) Community * (low risk of bias)
	b) Does not clearly describe (uncertain risk of bias)
Definition of the control group	a) No previous history of the syndrome * (low risk of bias)
	b) Does not clearly describe (uncertain risk of bias)

* Represents an item with the classification of low risk of bias.

Chart 2 Anemia and Frailty Syndrome (defined criteria). Belo Horizonte, Minas Gerais, 2017.

Author(s)	Type and objective of study	Participants and measure of frailty	Result	Outcome
Corona et al. (2014)	Cross-sectional study based on SABE. The objective was to evaluate the association between anemia, hemoglobin and frailty.	1345 participants. Complete frailty criteria (Fried) not used.	2.5-fold increase in probability of frailty. 12mg /dlHb = 30%. Women = 25%. 14mg/dlHb. Frailty: men = 10% and women <10%.	Positive association between anemia and frailty.
Silva et al. (2014)	Cross-sectional study based on FIBER. The objective was to evaluate the association between frailty, inflammatory markers and hemoglobin.	255 participants. Frailty assessed with WHAS criteria.	Reduction of hemoglobin associated with frailty, sarcopenia, and weight loss.	Positive for the association between anemia and frailty in women.
Llibre et al. (2014)	Longitudinal study based on the Cuban cohort. The objective was to identify the prevalence and incidence of frailty, risk factors (anemia) and incidence of functional dependence.	2813 participants. Frailty criteria (Fried) were modified.	Greater frailty in women (educational level and marital status as protective factor for frailty).	Anemia as a risk factor for the prevalence of frailty (prevalence rate of 1.64% - CI (1.23 - 2.20).

Chart 3 Anemia and functional capacity. Belo Horizonte, Minas Gerais, 2017.

Author(s)	Type of study and objective	Participants and measure of functional capacity	Results	Outcome
Patel et al. (2007)	Longitudinal study based on 15% of the cohort Health Aging and Body compositional study (ABC). The objective was to check whether functional changes varied in the presence of anemia among black and white skinned persons, and to observe differences between cut-off points for anemia.	2,601 participants. Evaluation of mobility through self-reporting. Functional changes: walking, climbing stairs and activities of daily living.	Hemoglobin levels vary according to skin color/ethnicity.	The presence of anemia is associated with a higher risk (2 to 3 times) of mortality and functional disability in white elderly persons. In black elderly persons functional capacity is greater, suggesting that the cut-off point for this group should be lower.
Haslamet et al. (2012)	Cross-sectional study based on the Georgia Centenarian Study (GCS). The objective was to evaluate the association between anemia and functional capacity in elderly people.	244 participants. Physical function measured through handgrip strength and knee extension, instrumental activities of daily living (SPPB).	Centenarian elderly persons with anemia exhibited greater loss of muscle strength, but there was no difference in activities of daily living. The sample was not described. High mortality rate among elderly people.	Anemic centenarian elderly persons exhibited a reduction in grip and lower limb strength with no impact on activities of daily living.
Contreras et al. (2015)	Longitudinal study based on Octabaix cohort. The objective was to analyze the prevalence of anemia in the elderly and the association with mortality after 3 years of follow-up.	328 participants. Tests used: Barthel, Lawton, Tinetti scale - POMA.	Higher mortality in anemic elderly persons, who had a worse perception of quality of life.	Higher mortality in anemic elderly, who had a worse perception of quality of life. Presence of an association between anemia and physical function.
Liu et al. (2015)	Cross-sectional study based on Rugão cohort. The objective was to evaluate the association between anemia and mortality in elderly individuals aged 95 years or older.	435 participants. Tests: basic and instrumental activities of daily living, squatting, ability to raise hands above head level. Non-detailed evaluation tools.	Anemia associated with all causes of mortality. Women with anemia were more physically dependent than men.	Presence of association between anemia and physical function.

Chart 4.Assessment of bias risk according to the adaptation of the Newcastle-Ottawa Scale. Belo Horizonte, Minas Gerais, 2017.

Article (year)	Obtaining the independent variables	Evaluation of frailty	Representativeness of samples	Selection of participants	Definition of the control group or cohort
Corona et al. (2014)	U	H	U	L	-
Silva et al.(2014)	U	L	U	L	-
Llibre et al.(2014)	L	U	U	L	L
Patel et al.(2007)	L	H	U	L	L
Haslamet et al. (2012)	U	H	U	L	-
Contreras et al.(2015)	L	H	U	L	L
Liu et al(2015)	U	H	U	L	-

Classification of items: H - high risk of bias; B - low risk of bias; I - uncertain risk of bias.

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Anemia and the frailty syndrome amongst the elderly living in the community: a systematic review

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[1] Correspondence Barbara Gazolla de Macêdo barbaragazolla@terra.com.br