Frailty syndrome among elderly and associated factors: comparison of two cities*

Objective to compare the frailty syndrome among elderly people living at home in two Brazilian cities and to identify factors related to sociodemographic and health-related variables. Method population-based cross-sectional study with 480 elderly individuals from the cities of Ribeirão Preto/SP and João Pessoa/PB, with application of the Mini Mental State Examination instruments and the Edmonton Frailty, Geriatric Depression and Lawton and Brody scales. Descriptive analysis, Chi-square test, Fisher’s test, Student’s t-test, Spermann’s correlation and Logistic regression were used. In all analyzes, the level of significance was set at p≤0.05. Results in relation to frailty, it was verified that living in Ribeirão Preto, presenting advanced age, low schooling, multiple chronic diseases, reduced cognitive status and functional capacity, besides depressive symptoms, are factors associated with the frailty syndrome, in both cities. Conclusion we identified that the frailty syndrome in the elderly of both cities has a relation with the place where the elderly person lives, age, schooling, number of diseases, reduction of cognitive status, functional capacity and presence of symptoms depressive.


Introduction
In a global context of population aging, in Brazil, there has been an accelerated increase in the proportion of the elderly. In 2010, according to a survey by the Brazilian Institute of Geography and Statistics (IBGE), there were a total of 23.5 million people aged 60 or over, and by 2013 this number reached 64.8 million. It is also noted an increase in life expectancy, with projections that reach, by 2041, 80 years (1) .
The aging process is accompanied by a set of physiological, psychological and social changes that can trigger multiple syndromes, among them the frailty (2) .
Frailty is a state of multidimensional change in which there is increased vulnerability and loss of resistance to external stressors, which increases the chance of certain adverse health events such as decreased strength, endurance and physiological function (3) . Under these conditions, the risk of dependence and/or death is high (4) .
In order to define frailty, the Canadian Initiative on Frailty and Aging (CIF-A) elaborated the concept based on a holistic approach determined by biological, psychological and social factors related to the life trajectory of the elderly (5)(6) .
In a systematic review with 19 articles, the authors verified the prevalence of frailty in the elderly between 2.3% and 75.0% (7) . Research indicates that frailty is associated with demographic factors, such as female sex and old age (7)(8) , and with clinical conditions, such as decreased functional capacity and cognitive status (9) , increased number of falls and hospitalizations (10) and death (11) .
In Brazil, there are few studies on the subject, especially those comparing two cities that can be influenced by the inequalities present in the different Brazilian regions, mainly life expectancy, low schooling, monthly income, housing and health conditions of the elderly, and conflicting house arrangements, in addition to suffering difficulties in the attention to healthcare.
Thus, in view of the accelerated aging process and the importance of investigating situations that contribute to frailty in the elderly, this study aims to compare the frailty syndrome among elderly people living at home in two Brazilian cities and to identify factors related to sociodemographic and health variables.

Method
This is an analytical and cross-sectional study carried out in the cities of Ribeirão Preto, located in the Southeast region, northeast of the state of São Paulo, and João Pessoa, capital of the Paraíba state, located in the Northeast of Brazil. Both have a similar number of inhabitants: 682,302 and 811,598, respectively (12) .
The following criteria were defined for participation in the study: being 60 years of age or older, of both sexes, living in the urban area and being able to respond to the instruments of data collection. The exclusion criteria were elderly with neurological diseases and that after the first contact did not attend the researchers in up to three consecutive visits.
For the identification of the elderly, a sample was chosen by double-stage conglomerate. In the first, the sample unit was considered the census sector and, in the second, age over 60 years. The sample was calculated in each city to guarantee maximum error of 6.3% with 95% probability, in situation of maximum variability. To reach the value of 240 elderly people in each city to compose the sample, we planned to raffle 20 sectors in both cities and to ensure the sample self-weighting, for which we fixed the number of 12 elderly people by census sector.
Once the sector was chosen, a new lottery of the streets and blocks was made to identify the elderly people from the starting point, clockwise.
The data were collected in the two cities by teams composed of undergraduate and graduate students previously trained by the study coordinator in both cities to apply the different instruments. The elderly were   (15) and validated for the Portuguese language (16)(17) . The scale evaluates nine domains represented by 11 items: a) cognitive area with the clock test (1 item); b) general health status performance Time Up and Go for balance and mobility (1 item). The maximum score is 17 points and represents the highest level of frailty.

d) Geriatric Depression Scale (GDS), reduced
version of the original scale (18) and validated for the Portuguese language (19) , with dichotomous responses. The score ranges from zero (absence of depressive symptoms) to 15 points, with the cutoff point> 5 indicating the presence of symptoms.

e) Lawton and Brody scale, which evaluates
the Instrumental Activities of Daily Living (AIVD) (20) , adapted to the Brazilian context (21) , and encompasses more complex social

Results
Of the 480 (100%) elderly, there was a predominance, in both cities, of elderly women, aged 80 years or more and retirees. In relation to the marital status, in Ribeirão Preto, there was prevalence of elderly with a partner and, in João Pessoa, without a partner.
As for the family arrangement, in Ribeirão Preto, most elderly lived only with their spouses (29.6%) and in João Pessoa, with spouse, children and grandchildren (28.0%) ( Table 1).
In Joao Pessoa, women between 65 and 69 years old presented a mean score of frailty of greater magnitude in relation to men. Those who lived with their spouses reached a higher average in comparison with men who also lived with spouses (  (Table 4).
In the categorical variables, it was verified that, for Ribeirão Preto, the frailty score presented higher average than that of the city of João Pessoa. In addition, the elderly with cognitive deficit had a higher average of frailty when compared to those who did not present a cognitive deficit (Table 4).

Discussion
The frailty syndrome in the elderly of both cities investigated is related to the place where the elderly person lives, age, schooling, number of diseases, decrease in cognitive status and functional capacity and presence of depressive symptoms.
Age is a determining factor for the onset of this syndrome. In this study, it was observed that the risk of becoming frail increases over the years. A similar result was found in a study carried out in Turkey with 1,126 elderly people, in which the authors identified, in those aged 74-85, a greater likelihood of becoming frail, whereas in the group of elderly people over 85 this chance was 5.635 times greater (22) . Another study conducted in Brazil with 360 elderly individuals over 65 years of age found that individuals aged 80 years or older presented a 1.24 time higher risk of being frail when compared to those aged 65 to 79 years (23) .
The consequences and development of aging phenotypes are related to different domains, e.g. changes in body composition, imbalance between energy availability and demand, or deregulated signaling networks that maintain homeostasis and neurodegeneration with impaired neuroplasticity. These factors increase the susceptibility of the elderly, since they reduce the functional reserve, resistance to stress and make health unstable, which can trigger the frailty syndrome (24) .
The lower the schooling, the greater the risk of the elderly being considered frail. In Turkey (22) and in Japan (25) , the authors found that having low levels of schooling is related to frailty, perhaps because the elderly with low schooling have little or no access to health information. Maintaining a healthy behavior through regular physical exercises and an adequate diet decreases the risk of being considered frail (4) .
Advancing age brings cognitive and physical losses, which can be aggravated by the accumulation of effects inherent to the aging process itself, as well as by the greater presence of chronic diseases (26) , such Rev. Latino-Am. Enfermagem 2018;26:e3100.
In this research, it was verified that the greater the number of diseases presented by the elderly, the greater the probability that they will become frail. A survey conducted in Turkey with 1,126 elderly people identified a higher mean of chronic diseases among those considered frail (3.18 ± 1.72) compared to prefrail (2.08 ± 1.36) and non-frail (1.78 ± 1.25), which indicates that it is a factor that increases the risk for this syndrome (p <0.001) (22) .
The data also showed a relationship between frailty and decreased cognitive status. Similar results were found in China in a study with 1,045 elderly. The authors verified that those with physical frailty presented 2.28 times more chances of developing cognitive impairment (28) , as observed in a Brazilian study whose results showed a negative correlation between both variables (r = -0.513, p <0.001) (29) .
Both frailty and decreased cognitive status are frequent conditions in the elderly, usually related to accumulation of molecular and cellular damage, hormonal and inflammatory dysregulation (30) . It is also common that they present neurological pathologies, cardiovascular diseases, decreased food intake, isolation and social vulnerability (31) . All these factors interact with each other and can influence the cycle of frailty and cognition (32) .
The IADL in the frail elderly showed an inverted relationship, that is, a lower functional capacity, which shows that the elderly are more likely to be frail. In Korea, results from a study of 196 elderly people showed that the frail elderly had greater limitations in the AIVD compared to those who were not frail (p <0.001) (33) .
In cases of frailty syndrome, there may be decreased muscle strength, reduced gait velocity and low tolerance to exercise. Consequently, there will be decreased secretion of the hormones estrogen, testosterone, luteinizing and dehydroepiandrosterone (34) .
Physical inactivity is considered the fourth factor that increases the risk of being frail, only behind overweight, obesity, increased chronic diseases and death (35) .
Promoting the regular practice of physical activity among frail elderly people can increase functional capacity and contribute to an active aging.
In the analysis of the elderly of both cities, those shown that elderly people with depressive symptoms are more likely to be frail. Data obtained from systematic reviews verified that the prevalence of both (depression and frailty) was of 38.60% (36) and its co-occurrence was greater than 10% (37) . Both conditions may be related to the decline process, since depression is associated with decreased muscle strength and physical activity (38) .
Physiologically, the mechanisms of both conditions are overlapping and involve changes such as subclinical vascular diseases that cause prefrontal white matter hyperintensities, chronic inflammation, oxidative stress, mitochondrial dysfunction, and hypothalamic-pituitaryadrenal axis (HPA) and interleukin 6 dysregulation (36) .
It is important to point out that the present study has two limitations: the first one is related to the crosssectional design adopted in both cities, which does not allow to infer the cause and effect between the variables investigated; and the second one concerns the comparison of the findings of the study with other studies, since there is no standardization of the instruments to evaluate this syndrome in the elderly, that is, it is a complex phenomenon that involves physical, psychological aspects, as well as social factors.
Thus, recognizing that frailty is a progressing syndrome with associated factors, it is the responsibility of health professionals to perform a more detailed evaluation in the various correlated aspects, with a view to interventions that can minimize it.

Conclusion
The results of this study revealed a predominance of female elderly, over 80 years old and retired. In Ribeirão Preto, elderly people with a partner or who lived with the spouses prevailed. In João Pessoa, there was a predominance of the elderly without a partner and a family arrangement formed by other elderly, children and grandchildren.
Among the factors related to frailty, it was verified that living in Ribeirão Preto, presenting advanced age, low schooling, multiple chronic diseases, reduced cognitive status and functional capacity, and depressive symptoms are factors associated with the frailty syndrome.
The study contributes to the identification of the level of frailty in the elderly, which is a risk factor for the occurrence of falls, dependence, institutionalization and death. The objective of the evaluation is to identify the elderly's deficits and prevent them, thus providing an improvement in the living conditions of this population.