Incidence of frailty and factors associated with functional deterioration in oldest old during the covid-19 pandemic: A cohort study

Abstract

Objective

To assess the incidence of frailty in oldest old during the covid-19 pandemic and to evaluate the associations between the domains of the Clinical-Functional Vulnerability Index (IVCF -20) and frailty.

Methods

A cohort study of 64 non-frail oldest old was conducted. Participants were evaluated at two timepoints: at baseline up to one year before the onset of the pandemic; and at follow-up, with an average interval between the two timepoints of 15 months. Frailty was assessed using the VS – Frailty (baseline) and remote application of the IVCF-20 (follow-up).

Results

Mean participant age was 88.7±5 years and the incidence of frailty was 20.6%. Frail participants exhibited greater dependence shopping (p<0.001), controlling their own money (p<0.001) and doing housework (p=0.010), as well as bathing alone (p=0.041). Cognitive decline was more prevalent in the frail individuals. The presence of despondency sadness or hopelessness proved high (92.3%) and was associated with frailty (p<0.001). On the multivariate analysis, frailty was associated with worsening forgetfulness (RR=2.39; 95%CI 1.27-4.46), loss of interest and pleasure in performing activities (RR=4.94; 95%CI 1.98-12.35) and fecal/urinary incontinence (RR=2.40; 95%CI 2.91-1.53).

Conclusions

Keywords
Frailty; Aged 80 and over; Telemedicine; Covid-19

Resumo

Objetivo

Avaliar a incidência de fragilidade na pessoa idosa longeva, durante a pandemia da covid–19 e identificar as associações entre os domínios do Índice de Vulnerabilidade Clínico Funcional (IVCF -20) e a fragilização.

Métodos

Estudo de coorte com 64 pessoas idosas longevas previamente não frágeis, avaliados em dois momentos: na linha de base, até um ano antes do início da pandemia e no seguimento, com uma média de intervalo entre os dois momentos de 15 meses. A fragilidade foi avaliada por meio do VS – Frailty (linha de base) e aplicação remota do IVCF-20 (seguimento).

Resultados

A idade média foi de 88,7±5 anos e a incidência de fragilidade de 20,6%. As pessoas idosas que fragilizaram apresentaram maior dependência em: deixar de fazer compras (p<0,001), deixar de controlar o próprio dinheiro (p<0,001) e deixar de fazer trabalhos domésticos (p=0,010), assim como em: deixar de tomar banho sozinho (p=0,041). A piora da cognição foi mais presente nos idosos que fragilizaram. A presença de desânimo, tristeza ou desesperança foi elevada (92,3%) e teve associação com a fragilização (p<0,001). Na análise multivariada, a fragilização esteve associada com piora do esquecimento (RR=2,39; IC95% 1,27-4,46), perda de interesse e prazer na realização de atividades (RR=4,94; IC95% 1,98-12,35) e incontinência esfincteriana (RR=2,40; IC95% 2.91-1,53).

Conclusões

A incidência de fragilização entre as pessoas idosas longevas durante a pandemia foi alta. Identificou-se que mais de um domínio foi afetado o que reforça a necessidade de avaliação da pessoa idosa em sua integralidade, sobretudo em períodos atípicos como o vivenciado.

Palavras-Chave:
Fragilidade; Idoso de 80 Anos ou mais; Telemedicina; Pandemia por covid-19

INTRODUCTION

The oldest old, individuals aged ≥80 years, is the fasting growing age group worldwide and, in Brazil, represents around 15% of the older population¹. While most projections consider age only, the population does not age homogenously, where older individuals have different degrees of vitality or frailty².

Level of vitality depends on homeostatic reserve and the body´s ability to cope with negative health events². In this respect, age is a risk factor for loss of vitality and frailty, but not a determinant of this outcome². Healthy aging can be defined as preservation of global functioning of older adults, supported by autonomy (cognition, mood and behavior) and independence (mobility and communication)³ which enable well-being in aging⁴.

Thus, the dynamic of aging is complex, involving a balance of the individual´s intrinsic capacity, the environment, and interaction between these two, shaped by resiliience⁴. Adverse situations, such as the emergence of the novel coronavirus⁵, can disrupt this dynamic.

The covid-19 pandemic was officially declared in March 2020, with ensuing recommendations for social distancing and lockdowns⁶. Although the same environment can affect older adults differently and in highly disparate ways⁶, social distancing and lockdown measures can have secondary impacts on the health of the population. These affects include psychological factors with worsening of anxiety and depressive symptoms associated with social disconnection, in addition to life-style changes, such as reduced level of physical activity, which can influence physical health and have a negative impact on functioning⁸. All of these changes can contribute to the development of frailty⁹,¹⁰ on a broader level, particularly in the oldest old who are at higher risk of becoming frail. However, to date, most related studies have been conducted in developed countries and fail to stratify older adults into sub-age groups.

The primary measure of the multidimensional aspect of health of older adults is the Comprehensive Geriatric Assessment (CGA), a tool for identifying and managing frail older people¹¹. However, the instrument takes a long time to apply and must be administered by specialized teams ¹². Moraes et al.¹² devised the shorter Clinical-Functional Vulnerability Index-20 (IVCF-20), an instrument for detecting clinical-functional vulnerability¹². This screening is carried out by means of a questionnaire scale which uses the CGA as a reference standard. The index, similarly to the CGA, is designed to collect information on the indicators age, self-rated health, activities of daily living, cognition, mood, mobility, communication and multiple comorbidities¹².

Therefore, based on the hypothesis that lockdown and social distancing can contribute to the development of frailty in non-frail older adults, the objective of the present study was to assess the incidence of frailty during the covid-19 pandemic and evaluate the associations between the domains of the IVCF-20 and the development of frailty.

METHOD

A cohort study of oldest old treated at the Healthy Aging Clinic of the Jenny de Andrade Faria Institute of the Clinical Hospital from the Federal University of Minas Gerais, Brazil, was conducted. The clinic is part of the Referral Center for Older Adults. The study involved two assessment timepoints: baseline – between March 2019-2020; and follow-up – between November 2020 and October 2021, with an average interval between timepoints of 15 months.

The inclusion criteria were: older adults of both genders, aged ≥80 years, and non-frail 12 months before the onset of the pandemic, defined as March 2020 according to the WHO declaration⁶. Centenarians were included irrespective of their functional status, being considered examples of healthy aging¹³. Older adults who did not possess a telephone to allow remote contact and data collection were excluded from the study.

Frailty at baseline was classified according to the multidimensional frailty model of Moraes et al.¹⁴ under which Clinical-Functional Classification is categorized on the Visual-Analogue Scale of Frailty (VS–Frailty). With this model, older people are classified into categories (1-10) based on the progressive reduction in vitality associated with increase in frailty¹⁴. Non-frail older individuals are classified into the 1-5 category. The use of this method is consistent with the WHO International Classification of Functioning with an emphasis on functioning¹⁴.

During follow-up, given the social distancing and lockdown down measures in place and discontinuation of elective visits at the clinic, frailty was assessed by applying the IVCF–20 (https://www.ivcf20.org) remotely. This instrument was chosen for its ease of application in remote form. The questionnaire was applied over the telephone by previously trained researchers.

Of the total eligible patients (134), 68 could not be contacted: 13 because they did not possess a telephone and 55 because the number registered was not the patient´s or the call did not go through. There were no cases of death due to infection by covid-19. The final sample is depicted in Figure 1:

Figure 1
Sample selection based on total number of patients enrolled at Healthy Aging Clinic, 1 year prior to covid-19 pandemic.

The IVCF–20 comprises 20 items divided into 8 domains, namely: age (1 item); self-rated health (1 item); functional disabilities, subdivided into basic and instrumental activities of daily living (4 items); cognition (3 items); mood (2 items); mobility, subdivided into reach, grasp, and pincer grip, aerobic capacity and/or muscle strength including unintentional weight loss, body mass index (BMI), calf circumference and gait speed, and fecal/urinary incontinence (6 items); communication, which includes vision and hearing (2 items); and multiple comorbidities, including polypathologies, polypharmacy and recent hospitalization (1 item).

Owing to the fact the questionnaire was applied over the telephone, the mobility domain did not include the calculation of BMI, measurement of calf circumference or timings of gait speed, as per adaptations for remote application¹⁵. Each domain has specific scoring with maximum of 40 points. A total score in the 0-6 points range indicates the respondent has low clinical-functional vulnerability and is likely robust. A score of 7-14 points suggests the respondent is at risk of becoming frail (pre-frail), while a score of ≥15 points suggests the individual is frail (high clinical-functional vulnerability)¹². Robust older adults are individuals who are independent for all basic and instrumental ADLs, irrespective of having diseases or otherwise. Individuals at risk of becoming frail retain their independence but have chronic conditions that predict functional decline, such as multiple comorbidities, sarcopenia or mild neurocognitive disorder. Frail individuals exhibit functional decline².

On the statistical analysis, the normality of the continuous variables was checked using the Kolmogorov-Smirnov test. Continuous variables displaying a normal distribution were expressed as mean and standard deviation, whereas categorical variables were expressed as absolute number and percentage. Categorical variables were compared using Pearson´s chi-square test or Fisher's Exact test, depending on the proportion of expected frequencies <5. Development of frailty was determined based on change in functional status between baseline and follow-up. Although two different methods (VS-Frailty and IVCF-20) were used for comparing functional status, they have a high positive correlation, given that both are designed to identify older individuals who are frail¹².

The Poisson Regression model with robust variance was employed to explore the relationship of change in functional risk (worsening or stable risk of vulnerability) with the categories of the IVCF-20. Predictor variables with a p-value of <20% (p<0.20) on the bivariate analysis were added one by one into a multivariate regression model using the forward method. Non-significant variables were excluded and a new variable included reiteratively until inclusion of all variables. The procedure was repeated until all variables present in the model were statistically significant (p<0.05). The Hosmer-Lemeshow test was used to check the goodness-of-fit of the final model. The relative risk (RR), with a 95% confidence interval (95%CI), was used as the measure of effect. For all statistical analyses, a level of significance of p<0.05 was adopted. Given that the sample could not be calculated a priori because the number of patients enrolled and contactable by telephone was pre-defined, analysis of the power of the tests (post-hoc) was performed using the G*Power 3.1 software, where a minimum power of 80% was defined.

The study was approved by the Research Ethics Committee of the University (CAAE: 80295616.1.0000.5149 and approval permit no: 2422800).

RESULTS

The final sample comprised 64 older adults, of which 40 (62.5%) were female. Participants had a mean age of 88.7 ±5 years and 27 (42.2%) were nonagenarians or centenarians. Three individuals (4.7%) became infected by the coronavirus during the study period, 2 of whom became frail following the infection. However, none of these patients died as a result of SARS-COV-2. One year prior to the pandemic, 98.4% of participants were non-frail and only 1 (1.6%) individual (a centenarian) was frail.

Frailty incidence during the pandemic was 20.6% (13 individuals) (Table 1).

Table 1
. Development of frailty of oldest old during SARS-COV-2 pandemic. Belo Horizonte, Brazil 2020 – 2021.

Frailty status	Baseline	Follow-up	Frailty incidence
	N (%)	N (%)	N (%)
Non-frail	63 (98.4)	50 (78.1)	+13 (20.6)
Frail	1 (1.6)	14 (21.8)

Comparison of the IVFC-20 regarding development of frailty (Table 2) revealed no group differences only for the variables falls (p=0.092) and reach, grasp and pincer grip (inability to raise arms above shoulder level (p=0.052) and inability to handle/hold small objects (p=0.289). Test power was high for variables exhibiting statistical significance, except for the variables no longer bathes alone or does domestic chores (0.34 and 0.73, respectively).

Table 2
Comparison of oldest old developing and not developing frailty, by domain and respective items of IVCF-20, during covid-19 pandemic. Belo Horizonte, Brazil 2020 – 2021.

IVCF-20 domains	Developing frailty (n=13)	Not developing frailty (n=51)	p-value*
Age
≥ 85 years	13 (100%)	33 (64.7%)	0.013a
Self-rated health
Fair or poor	8 (61.5%)	7 (13.7%)	< 0.001a
Dependence for IADLs
No longer does shopping	8 (61.5%)	6 (11.8%)	< 0.001a
No longer controls money	5 (38.5 %)	3 (5.9%)	< 0.001a
No longer does domestic chores	4 (30.8%)	3 (5.9%)	0.010b
Dependence for BADLs
No longer bathes alone	2 (15.4%)	1 (2.0%)	0.041b
Cognition
Forgetfulness perceived by others	9 (69.2%)	8 (15.7%)	< 0.001a
Recent worsening of forgetfulness	6 (46.2%)	3 (5.9%)	< 0.001a
Forgetfulness impacting daily activities	6 (46.2%)	1 (2.0%)	< 0.001a
Mood
Despondency, sadness or hopelessness	12 (92.3%)	15 (29.4%)	< 0.001a
Loss of interest/pleasure in activities	9 (69.2%)	4 (7.8%)	< 0.001a
Mobility
Inability to raise arms above shoulder level	5 (38.5%)	4 (7.8%)	0.052a
Inability to handle small objects	1 (7.7%)	1 (2.0%)	0.289b
Aerobic capacity – weight loss	6 (46.2%)	9 (17.6%)	0.030a
Walking difficulties	6 (46.2%)	4 (7.8%)	0.001a
Falls	4 (30.8%)	6 (11.8%)	0.092b
Fecal/urinary incontinence	9 (69.2%)	9 (17.6%)	<0.001a
Communication
Vision problems	7 (53.8%)	6 (11.8%)	0.001a
Hearing problems	7 (53.8%)	10 (19.6%)	0.003a
Multiple comorbidities	8 (61.5%)	15 (29.4%)	0.031a

• *Chi-squared test; ^a: test power ≥0.80; ^b: test power <0.80. IVCF: Clinical-functional vulnerability index; IADLs=Instrumental Activities of Daily Living; BADLs=Basic Activities of Daily Living

The analysis of Poisson Regression of robust variance exploring the association of frailty (presence or otherwise) with the IVCF-20 domains revealed a 2.39 times greater frailty incidence in individuals who experienced worsening of forgetfulness, 4.94 greater in those reporting loss of interest/pleasure in activities, and 2.4 times greater incidence in participants with fecal/urinary incontinence (Table 3).

Table 3
Poisson Regression analysis with robust variance for development of frailty during covid-19 pandemic. Belo Horizonte, Brazil 2020 – 2021.

Explanatory variables	RR	95%CI	p-value
Worsening of forgetfulness
No	1
Yes	2.39	1.27 – 4.46	0.006
Loss of interest/pleasure in activities
No	1
Yes	4.94	1.98 - 12.35	0.001
Fecal/urinary incontinence
No	1
Yes	2.40	2.91 - 1.53	<0.001

• CI = Confidence Interval; Goodness-of-fit =1.00

DISCUSSION

The present study shows deterioration for several functional domains in the sample of older adults investigated. Taken together, the speed of the declines observed (20% frailty incidence within the space of just 15 months), the temporal link with the pandemic and biological plausibility, strongly suggest that these outcomes are secondary effects of the covid-19 pandemic. Interestingly, the low rate of infection by Sars Cov-2 (4.7%) in the population studied also suggests that the infection itself (direct effect of pandemic) was not the root cause of this process of worsening frailty.

The most notable domains affected were those related to cognition (recent worsening of forgetfulness), mood (loss of interest or pleasure engaging in previously enjoyable activities) and fecal/urinary incontinence. These findings contradict the popular belief that declines in older adults during lockdown chiefly involved mobility. Studies conducted globally have shown these impacts⁸,⁹,¹⁶,¹⁷, but scant data are available on the oldest old population in Brazil.

In the present study, the Clinical-Functional Vulnerability Index (IVCF-20) was applied for its high correlation with the multidimensional evaluation of older people², revealing that around 20% of the older adults assessed became frail during the study period. A previous longitudinal study conducted in Japan found a frailty incidence of 16% in community-dwelling older adults (mean age 73 years) who were robust prior to the pandemic. The study found that lockdowns and low level of physical activity contributed to greater frailty in these individuals¹⁶.

In another study, involving a Chinese cohort, around 12% of older adults who were non-frail before the pandemic became frail during the outbreak¹⁷. The study found that the change in frailty transition status was associated with presence of multimorbidity and psychological distress. However, the age of the study population averaged 70 years, and frailty was evaluated using the criteria of Fried et al.¹⁸, which are not multidimensional, covering physical aspects only.

In the present study, the population assessed was older, a factor which might explain the high incidence of frailty detected. Although age is not a determinant of frailty¹⁹, it is a relevant predisposing factor, particularly in the oldest old²⁰. Nevertheless, a 2019 meta-analysis of individuals aged ≥60 years reported an annual frailty incidence of 4.0%, as measured using the Fried et al.¹⁸ criteria, with this rate rising to 7.0% when other frailty criteria were taken into account²¹. In another study²², also determining incidence but stratifying by age, the frailty rate was 22.6% in Europeans aged >85 years over a 4-year period, classified using criteria of Fried et al¹⁸. Hence, the frailty incidence found in the present study population was relatively high, given the short timeframe of only 15 months.

Moreover, the study employed an instrument which includes questions that encompass all functional domains and not just physical aspects, an important point given that deterioration in cognition and mood were found to be associated with functional decline.

Also, a high percentage of individuals who developed frailty exhibited a worsening of mood. Approximately 92% of older adults reported sadness, despondency or hopelessness. Loss of interest and pleasure in activities was the variable which showed the strongest association with subsequent development of frailty. This finding is consistent with other studies investigating mental health during the pandemic²³,²⁴, albeit higher in magnitude.

In a previous cross-sectional study assessing psychological aspects of older people seen at a geriatrics service who were dependent for some activities found that 70% of individuals experienced low mood at least some of the time after social isolation²⁵. Some studies, one involving a Chinese cohort¹⁷ and another in a Japanese population²⁶, also found increased psychological distress in individuals who become frail and greater depressive symptoms attributed to social isolation, respectively. Those older adults with depressive symptoms were more prone to cognitive decline and decreased performance of ADLs²⁶. It is believed that the conflicting information conveyed by official health channels in Brazil may have negatively impacted mental health.

Cognitive decline was also evident as a characteristic in the group of older adults who became frail. Studies prior to the pandemic had showed a relationship between social isolation and cognitive function. In a 2-year cohort study involving over 2,000 healthy older people on the Cognitive Function and Ageing Study-Wales, social isolation was associated with cognitive reserve, and individuals with greater reserve also had greater cognitive function²⁷. The same study found an association of social isolation with orientation, expression and perception, but not with memory or attention. This finding contradicts the results of a 2019 study of a sample that included 10,000 participants from the English Longitudinal Study of Aging (ELSA)²⁸ showing that social isolation was associated with memory decline in older adults, consistent with the present study in which cognition was assessed by questions focused on memory only.

Memory is related with capacity for execution, motor ability and functional activity, and is deemed one of the most complex domains²⁹. Consequently, memory deficits have a negative impact on functioning in older people. Social isolation implies lower social interaction and, hence, lower cognitive stimulation among older individuals who, besides having lower cognitive reserve, encounter difficulties maintaining social contact using other channels of communication that are not face-to-face.

Fecal/urinary incontinence, another domain assessed on the IVCF-20, is a common condition in the older population that is associated with functional decline and frailty³⁰. In the present study, the incidence of frailty was associated with incontinence, although urinary incontinence was not distinguished from fecal incontinence. Previous evidence shows that functional disability is a risk factor for urinary incontinence in older adults³⁰, but also a consequence of this problem.

In a study of non-institutionalized participants from The Irish Longitudinal Study on Ageing (TILDA)³⁰ without severe cognitive impairment, urinary incontinence was associated with ADL limitations, and also associated with loneliness and depressive symptoms. In another cross-sectional study³¹, assessing community-dwelling older adults with urinary or fecal incontinence, these conditions were found to be associated with worse mental health and reduced social interaction.

In the present study, older adults exhibited cognitive decline, but the relation between incontinence and cognitive ability appears to be bi-directional³². Fecal/urinary incontinence has hitherto not been investigated in the literature as a possible secondary effect of the pandemic on the health of older people. However, incontinence is known to be a multifactorial condition involving physical issues (such as use of medications), as well as aspects related to mood and cognition.

Another important finding of the study pertains to sensory losses. Hearing and vision deficits are associated with worse functioning, even though this variable was not retained in the multi-causal model. A Japanese cohort study revealed greater dependence in ADLs among participants with hearing difficulty³³. This factor was measured by self-report, as was the case in the present study. In a recent review, frailty risk was greater in older people with hearing loss, while a 4-year cohort study showed that hearing impairment was associated with higher risk of frailty³⁵. Older individuals with hearing impairment also have less social interaction, possibly influencing other domains (e.g. cognition) and further increasing the risk of frailty.

The present study has several strengths, including the assessment of non-frail oldest old using an easily applied instrument for assessing functioning remotely, a critical factor during the pandemic. Moreover, although the sample was not calculated a priori, the power of the tests was high for the majority of the associations displaying significant differences between individuals who developed frailty and those who did not. However, the study has some limitations, such as the use of two different instruments for assessing frailty, and the absence of variables related to multi-causality of the outcome that might have better elucidated the risk factors for developing frailty. Another limitation was the fact that some participants did not possess a telephone, precluding contact. Finally, the information was collected by self-report, although many studies have used this method, including during the pandemic, yielding satisfactory results.

It is important to bear in mind that other factors, besides the covid-19 pandemic, may have influenced the functioning of the participants during the period studied. However, given the group assessed was healthy prior to the pandemic and undergoing treatment at a referral center, even throughout the pandemic (remotely in this case), social isolation imposed by the pandemic is believed to be the main factor driving the functional decline observed.

CONCLUSION

The incidence of frailty in the oldest old during the pandemic proved high. More than one domain was impacted, highlighting the need for broad assessment of older individuals as a whole, particularly during atypical periods such as the recent pandemic.

The study provided a picture of the health status of the older adults followed during a period when access to health services was impacted due to lockdown measures, which also served to ensure delivery of care interventions to those most in need of treatment. In addition, these results underscored the role of mental health aspects in this population, having implications for planning interventions to improve psychological care in this group.

• No funding was received in relation to the present study.

REFERÊNCIAS

• ¹
  Instituto Brasileiro de Geografia e Estatística. Evolução dos Grupos Etários no Brasil, 2010-2060. Disponível em https://www.ibge.gov.br/apps/populacao/projecao/ Acessado em 15 de novembro de 2021.
  » https://www.ibge.gov.br/apps/populacao/projecao/
• ²
  Moraes EN, Moraes FL. Avaliação multidimensional do idoso. 5ª ed. Belo Horizonte: Folium; 2016.
• ³
  Moraes, EN. Atenção à saúde do idoso: Aspectos Conceituais. 1ª ed. Brasília, 2012.
• ⁴
  World Health Organization. World Report on Ageing and Heathy, 2015.
• ⁵
  Malone ML, Hogan MT, Perry A, Biese K, Bonner A, Pagel P, Unroe KT. COVID-19 in Older Adults: Key Points for Emergency Department Providers. Jour of Geriatr Emerc Med. 2020;1(4):1-6.
• ⁶
  World Health Organization. Coronavirus Disease 2019: Situation Report – 72. April, 2020.
• ⁷
  Shi L, Lu Z, Que J, Huang X, Liu L, Ran MS, et al. Prevalence of and Risk Factors Associated With Mental Health Symptoms Among the General Population in China During the Coronavirus Disease 2019 Pandemic. JAMA Netw Open. 2020 1;3(7)1-16.
• ⁸
  Visser M, Schaap L, Wijnhoven HAH. Self-Reported Impact of the COVID-19 Pandemic on Nutrition and Physical Activity Behaviour in Dutch Older Adults Living Independently. Nutrients 2020; 30(12):3708.
• ⁹
  Maltese G, Corsonello A, Rosa MD, Soraci L, Vitale C, Corica F, et al. Frailty and COVID-19: A Systematic Scoping Review. J Clin. Med. 2020;4;9(7):2106.
• ¹⁰
  Shinohara T, Saida K, Tanaka S, Murayama A. Do lifestyle measures to conter COVID-19 affect frailty rates in elderly community dwelling? Protocol for crosssectional and cohort study. BMJ Open 2020;13;10(10): e040341.
• ¹¹
  Turner G, Clegg A. Best practice guidelines for the management of frailty: a British Geriatrics Society, Age UK and Royal College of General Practitioners report. Age and Ageing 2014; 43(6):744–747.
• ¹²
  Moraes EN, Carmos JA, Machado CJ, Moraes FL. Índice de Vulnerabilidade Clínico-Funcional-20: proposta de classificação e hierarquização entre os idosos identificados como frágeis. Rev Fac Ciênc Méd Sorocaba. 2020;22(1):31-5.
• ¹³
  Borras C, Ingles M, Mas-Bargues C, Dromant M, Sanz-Ros J, Róman-Domínguez, et al. Centenarians: An excellent example of resilience for successful ageing. Mech Ageing. 2020; 186:111199.
• ¹⁴
  Moraes EN, Lanna FM, Santos RR, Bicalho MAC, Machado CJ, Romero DE. A new proposal for the clinical-functional categorization of the elderly: visual scale of frailty (vs-frailty). J Aging Res Clin Pract. 2016; 5(1):24-30.
• ¹⁵
  Secretária Estadual de Saúde de Minas Gerais. Recomendações sobre a organização das redes de atenção à saúde para promover a reabilitação dos usuários que após a infecção pelo SARS-COV-2 apresentam sequelas funcionais e necessitam da continuidade dos cuidados, no âmbito do sistema único de saúde de Minas Gerais. Belo Horizonte, 2020.
• ¹⁶
  Yamada M, Kimura Y, Ishiyama D, Otobe Y, Suzuki M, Koyama S, et al. The Influence of the COVID-19 Pandemic on Physical Activity and New Incidence of Frailty among Initially Non-Frail Older Adults in Japan: A Follow-Up Online Survey. J Nutr Health Aging 2021; 25(6): 751-756.
• ¹⁷
  Wang Y, Fu P, Li J, Jing Z, Wang Q, Zhao D, et al. Changes in psychological distress before and during the COVID-19 pandemic among older adults: the contribution of frailty transitions and multimorbidity. Age Ageing 2021; 50(4):1011-1018.
• ¹⁸
  Fried LP, Tangem CM, Walston J Newban AB, Hirsch C, Gottdiener J, Seeman RT, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001;56(3):M146-56.
• ¹⁹
  Moraes EN, Carmo JA, Moraes FL, Azevedo RS, Machado CJ, Montilla DER. Índice de Vulnerabilidade Clínico Funcional – 20 (IVCF -20): reconhecimento rápido do idoso frágil. Rev Saúde Pública. 2016; 50(81):1-8.
• ²⁰
  Pinheiro HA, Mucio AA, Oliveira LF. Prevalência e fatores associados à síndrome de fragilidade no idoso do Distrito Federal. Geriatr Gerontol Aging. 2020;14(1):8-14.
• ²¹
  Ofori-Asenso R, Chin KL, Mazidi M, Zomer E, Ilomaki J, Zullo AR, et al. Global Incidence of Frailty and Prefrailty Among Community-Dwelling Older Adults A Systematic Review and Meta-analysis. JAMA Netw Open. 2019;2(8):e198398.
• ²²
  Jazbar J, Pišek S, Locatelli I, Kos M. Prevalence and Incidence of Frailty Among Community-dwelling Older Adults in Slovenia. Zdr Varst. 2021;60(3):190-198.
• ²³
  Yan Y, Du X, Lai L, Ren Z, Li H. Prevalence of depressive and anxiety symptoms among Chinese older adults during the COVID-19 pandemic: A systematic review and meta-analysis. J Geriatr Psychiatry Neurol ; 2022;35(2): 182-195.
• ²⁴
  Sepúlveda-Loyola W, Rodríguez-Sánchez I, Pérez-Rodríguez P, Ganz F, Torralba R, Oliveira DV, et al. Impact of Social Isolation Due to COVID-19 on Health in Older People: Mental and Physical Effects and Recommendations. J Nutr Health Aging; 2020; 24(9): 938–947.
• ²⁵
  Bailey L, Ward M, DiCosimo A, Baunta S, Cunningham C, Outurno-Romero R, et al. Physical and mental health of older people while cocooning during the COVID-19 pandemic. QJM 2021;114(9): 648-653.
• ²⁶
  Noguchi T, Hayashi T, Kubo Y, Tomiyama N, Ochi A, Hayashi H. Association between Decreased Social Participation and Depressive Symptom Onset among Community-Dwelling Older Adults: A Longitudinal Study during the COVID-19 Pandemic. J Nutr Health Aging. 2021; 25(9):1070-1075.
• ²⁷
  Evans IEM, Llewellyn DJ, Matthews FE, Woods RT, Brayne C, Clare L. Social isolation, cognitive reserve, and cognition in healthy older people. PLoS One, 2018;13(8):e0201008.
• ²⁸
  Read S, Comas – Herrera A, Grundy E. Social Isolation and Memory Decline in Later-life. J Gerontol B Psychol Sci Soc Sci, 2020; 14;75(2):367-376.
• ²⁹
  Harvey PD. Domains of Cognition and Their Assessment. Dialogues. Clin Neurosci. 2019; 21(3): 227–237.
• ³⁰
  Stickley A, Santini ZI, Koyanagi A. Urinary incontinence, mental health and loneliness among community-dwelling older adults in Ireland. BMC Urol. 2017; 17(1):29.
• ³¹
  Yip SO, Dick MA, McPencow AM, Martin DK, Ciarleglio MM, Erekson E. The association between urinary and fecal incontinence and social isolation in older women. Am J Obstet Gynecol. 2013;208(2):146.
• ³²
  Su YY, YiTsai Y, LeeChu C, Lin CC, MinChen C. Exploring a Path Model of Cognitive Impairment, Functional Disability, and Incontinence Among Male Veteran Home Residents in Southern Taiwan. Sci Reports 2020; 10(1): 5553.
• ³³
  Yamada M, Nishiwaki Y, Michikawa T, Takebayashi T. Impact of hearing difficulty on dependence in activities of daily living (ADL) and mortality: A 3-year cohort study of community-dwelling Japanese older adults. Arch of Geron and Geriat. 2011; 52(3):245–249.
• ³⁴
  Tian R, Almeida OP, Jayakody DMP, Ford AH. Association between hearing loss and frailty: a systematic review and meta-analysis. BMC Geriatr, 2021;21(1):333.
• ³⁵
  Liljas AEM, Carvalho LA, Papachristou E, Oliveira CD, Wannamethee SG, Ramsay SE, et al. Self-Reported Hearing Impairment and Incident Frailty in English Community-Dwelling Older Adults: A 4-Year Follow-Up Study. J Am Geriatr Soc; 2017;65(5):958-965.

Edited by

Edited by: Yan Nogueira Leite de Freitas

Publication Dates

• Publication in this collection
  21 Nov 2022
• Date of issue
  2022

History

• Received
  24 Apr 2022
• Accepted
  03 Oct 2022