Abstracts
OBJECTIVE
To investigate the association between frailty syndrome and cognitive performance in the older adults and the effect of schooling and age on this association.
METHODS
Data on frailty in older adults from Phase 1 of the FIBRA-RJ Study were analyzed, relating to 737 customers of a private health care provider, aged 65 and over, living in Rio de Janeiro, Southeastern Brazil, between January 2009 and January 2010. Data on socioeconomic and demographic characteristics, medical conditions and functional capacity were collected. Cognitive performance was assessed using the Mini-Mental State Examination (MMSE). Individuals who exhibited three or more of the following features were considered to be frail: unintentional weight loss (≥ 4.5 kg in the last year); feeling self-reported exhaustion, low grip strength, low physical activity level and slowness. The association between frailty and cognitive performance was evaluated using multivariate logistic regression, with adjustment for medical conditions, activities of daily living and socioeconomic variables. We evaluated the age and schooling as possible effect modifiers in this association.
RESULTS
The frail subjects had a higher prevalence of low cognitive performance, compared to not frail or pre-frail, in the three age groups studied (65-74; 75-84; ≥ 85 years), p < 0.001. After adjustment, the association between frailty and cognitive performance was found among older adults individuals aged 75 and older, with an ORadj= 2.78 (95%CI 1.23;6.27) for those aged 75 to 84 and ORadj= 15.62 (95%CI 2.20;110.99) for 85 and older. The age variable was an effect modifier in the association between frailty and cognitive performance, χ2(5) = 806.97, p < 0.0001; the same was not the case with schooling.
CONCLUSIONS
Frailty syndrome is associated with cognitive performance in the aging. Age proved to be an effect modifier in this association. The oldest patients showed a more significant association between the two phenomena.
Aged; Frail Elderly; Cognition; Socioeconomic Factors; Health Maintenance Organizations; Cross-Sectional Studies
OBJETIVO
Analisar a associação entre a síndrome da fragilidade e desempenho cognitivo em idosos e respectivo efeito da escolaridade e da idade.
MÉTODOS
Foram analisados dados seccionais da fragilidade de idosos brasileiros da Fase 1 do Estudo FIBRA-RJ, relativos a 737 indivíduos residentes na cidade do Rio de Janeiro, RJ, com 65 anos ou mais, clientes de uma operadora de saúde, avaliados entre janeiro de 2009 e janeiro de 2010. Foram coletadas informações sobre características socioeconômicas e demográficas, condições médicas e capacidade funcional. O desempenho cognitivo foi avaliado através do Mini Exame do Estado Mental. Foram considerados frágeis os indivíduos que apresentaram três ou mais das seguintes características: perda de peso não intencional (≥ 4,5 kg no último ano); sensação de exaustão autorrelatada; baixo nível de força de preensão palmar; baixo nível de atividade física e lentificação da marcha. A associação entre fragilidade e desempenho cognitivo foi avaliada por regressão logística multivariada, com ajuste por condições médicas, atividades da vida diária e variáveis socioeconômicas. Idade e escolaridade foram avaliadas como possíveis modificadoras de efeito dessa associação.
RESULTADOS
Os idosos frágeis apresentaram maior prevalência de baixo desempenho cognitivo comparados aos idosos não frágeis ou pré-frágeis nas três faixas etárias estudadas (65 a 74; 75 a 84; ≥ 85 anos), p < 0,001. Após ajuste, a associação entre fragilidade e desempenho cognitivo foi encontrada em idosos com 75 anos ou mais, com OR aj = 2,78 (IC95% 1,23;6,27) para 75 a 84 anos e OR aj = 15,62 (IC95% 2,20;110,99) para 85 anos ou mais. A idade se comportou como modificadora de efeito na associação entre fragilidade e desempenho cognitivo, χ 2 (5) = 806,97, p < 0,0001; o mesmo não ocorreu com a escolaridade.
CONCLUSÕES
A síndrome da fragilidade associou-se ao desempenho cognitivo em idosos. A idade mostrou-se como modificadora de efeito nessa associação. Os idosos com idade mais avançada apresentaram associação mais expressiva entre os dois fenômenos.
Idoso; Idoso Fragilizado; Cognição; Fatores Socioeconômicos; Sistemas Pré-Pagos de Saúde; Estudos Transversais
OBJETIVO
Analizar la asociación entre el síndrome de la fragilidad y desempeño cognitivo en ancianos y respectivo efecto de la escolaridad y la edad.
MÉTODOS
Se analizaron datos seccionales de la fragilidad de ancianos brasileños de la Fase 1 del Estudio FIBRA RJ, relativos a 737 individuos residentes de la ciudad de Rio de Janeiro (Brasil), con 65 años o más, clientes de una operadora de salud, enero de 2009 a enero de 2010. Se colectaron informaciones sobre características socioeconómicas y demográficas, condiciones médicas y capacidad funcional. El desempeño cognitivo fue evaluado a través del Mini Examen del Estado Mental. Se consideraron frágiles los individuos que presentaron tres o más de las siguientes características: pérdida de peso no intencional (≥ 4,5 Kg en el último año); sensación de cansancio extremo auto-relatado; bajo nivel de fuerza de prensión palmar; bajo nivel de actividad física y lentitud en la marcha. La asociación entre fragilidad y desempeño cognitivo fue evaluado por regresión logística multivariada, con ajuste por condiciones médicas, actividades de la vida diaria y variables socioeconómicas. La edad y la escolaridad fueron evaluadas como posibles modificadoras del efecto de ésta asociación.
RESULTADOS
Los ancianos frágiles presentaron mayor prevalencia de bajo desempeño cognitivo en comparación con los ancianos no frágiles o pre-frágiles en los tres grupos etarios estudiados (65 a 74; 75 a 84; ≥ 85 años), p< 0,001. Posterior al ajuste, la asociación entre fragilidad y desempeño cognitivo fue encontrada en ancianos con 75 años o más, con ORaj = 2,78 (IC95% 1,23;6,27) para 75 a 84 años y ORaj = 15,62 (IC95% 2,20;110,99) para 85 años o más. La edad se comportó como modificadora de efecto en la asociación entre fragilidad y desempeño cognitivo, χ 2 (5) = 806,97, p < 0,0001; lo mismo no sucedió con la escolaridad.
CONCLUSIONES
El síndrome de la fragilidad se asoció con el desempeño cognitivo en ancianos. La edad se mostró como modificadora del efecto en ésta asociación. Los ancianos con edad más avanzada presentaron asociación más expresiva entre los dos fenómenos.
Anciano; Anciano Frágil; Cognición; Factores Socioeconómicos; Sistemas Prepagos de Salud; Estudios Transversales
INTRODUCTION
From the 1940s onwards, the age composition of the Brazilian underwent changes and, more significantly, after the 1960s the number of older adults increased considerably.a a Instituto Brasileiro de Geografia e Estatística. Indicadores sociodemográficos e de saúde no Brasil 2009. Rio de Janeiro; 2009. (Estudos e Pesquisas. Informações Demográficas e Socioeconômicas, 25). , b b Instituto Brasileiro de Geografia e Estatística. Projeção da população do Brasil por sexo e idade para o período 1980-2050: revisão 2008. Rio de Janeiro; 2009. (Estudos e Pesquisas. Informações Demográficas e Socioeconômicas, 24). There are 21 million individuals aged 60 and over in the country (11.1% of the total). In the Southeast, the number of older individuals is almost 10 million (12.4% of the total for the region) and there are more than two million (14.9%) in the state of Rio de Janeiro. a a Instituto Brasileiro de Geografia e Estatística. Indicadores sociodemográficos e de saúde no Brasil 2009. Rio de Janeiro; 2009. (Estudos e Pesquisas. Informações Demográficas e Socioeconômicas, 25). The Instituto Brasileiro de Geografia e Estatística (IBGE – Brazilian Institute of Geography and Statistics) revised population projections stating significant increases in the number of individuals ≥ 60 in 2008. This group will go from 13.9 million in 2000 to 28.3 million in 2020, reaching 64 million in 2050. a a Instituto Brasileiro de Geografia e Estatística. Indicadores sociodemográficos e de saúde no Brasil 2009. Rio de Janeiro; 2009. (Estudos e Pesquisas. Informações Demográficas e Socioeconômicas, 25).
Mean life expectancy increases year on year due to better control of environmental risks
and to improvements in medical interventions. However, many of the older adults who
survive have to bear the load of chronic disease, need more frequent medical attention,
consume more medicines and undergo more medical tests and hospitalizations. 22 . Boult L, Boult C, Pirie P, Pacala JT. Test-retest reliability of a
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Cognitive disorders in older adults are often associated with frailty. Frailty syndrome
has a multi-systemic character and reduces the organism’s capacity to respond
appropriately to adverse events when exposed to stressors. Frail individuals benefit less
from therapeutic interventions, the defence system is inefficient and interactions,
independence and quality of life are negatively affected. This condition results in
vulnerability to adverse health outcomes, with high rates of mortality, fractures and
falls and increases in hospitalizations and re-hospitalizations, incapacity, among others.
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As there are a great number of older
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Changes in cognitive functions, together with social, economic, demographic and health
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,
1919 . Raji MA, Al Snih S, Ostir GV, Markides KS, Ottenbacher KH. Cognitive
status and future risk of frailty in older Mexican Americans. J Gerontol A Biol
Sci Med Sci. 2010;65(11):1228-34. DOI:10.1093/gerona/glq121
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Raji et al 1919 . Raji MA, Al Snih S, Ostir GV, Markides KS, Ottenbacher KH. Cognitive
status and future risk of frailty in older Mexican Americans. J Gerontol A Biol
Sci Med Sci. 2010;65(11):1228-34. DOI:10.1093/gerona/glq121
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examined the association between cognition and risk of
becoming frail within 10 years in 942 elderly individuals, who were not frail at the
baseline. They confirmed the hypothesis that participants with poor cognitive functioning,
with scores below 21 in the Mini Mental State Exam (MMSE), 55 . Folstein MF, Folstein SE, McHugh PR. “Mini-mental state”: a practical
method for grading the cognitive status of patients for the clinician. J Psychiatr
Res . 1975;12(3):189-98. DOI:10.1016/0022-3956(75)90026-6
https://doi.org/10.1016/0022-3956(75)900...
had a greater risk of becoming frail than those with high
cognitive functioning (score of 21 or over in the MMSE). Other studies 2020 . Samper-Ternent R, Al Snih S, Raji MA, Markides KS, Ottenbacher KJ.
Relationship between frailty and cognitive decline in older Mexican Americans. J
Am Geriatr Soc . 2008;56(10):1845-52.
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,
2424 . Yassuda MS, Lopes A, Cachioni M, Falcão DV, Batistoni SS, Guimarães VV, et
al. Frailty criteria and cognitive performance are related: data from the FIBRA study in
Ermelino Matarazzo, São Paulo, Brazil. J Nutr Health Aging .
2012;16(1):55-61. examined frailty syndrome as a risk
factor in cognitive performance changes. Samper-Ternent et al 2020 . Samper-Ternent R, Al Snih S, Raji MA, Markides KS, Ottenbacher KJ.
Relationship between frailty and cognitive decline in older Mexican Americans. J
Am Geriatr Soc . 2008;56(10):1845-52.
DOI:10.1111/j.1532-5415.2008.01947.x
https://doi.org/10.1111/j.1532-5415.2008...
studied 1,370 individuals aged 65 and over in five
American states (Hispanic Established Population for the Epidemiological Study of the
Elderly), with cognitive performance ≥ 21 points in the MMSE 55 . Folstein MF, Folstein SE, McHugh PR. “Mini-mental state”: a practical
method for grading the cognitive status of patients for the clinician. J Psychiatr
Res . 1975;12(3):189-98. DOI:10.1016/0022-3956(75)90026-6
https://doi.org/10.1016/0022-3956(75)900...
and concluded that being classified as frail is a
significant risk factor in a decreasing MMSE score after 10 years.
Yassuda et al 2424 . Yassuda MS, Lopes A, Cachioni M, Falcão DV, Batistoni SS, Guimarães VV, et
al. Frailty criteria and cognitive performance are related: data from the FIBRA study in
Ermelino Matarazzo, São Paulo, Brazil. J Nutr Health Aging .
2012;16(1):55-61. carried out a study of
384 older individuals resident in Sao Paulo, SP, Southeastern Brazil. The objective was to
evaluate the association between the criteria of Fried et al 66 . 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;56(3):M146-57. DOI:10.1093/gerona/56.3.M146
https://doi.org/10.1093/gerona/56.3.M146...
in diagnosing frailty and cognitive performance. The
results showed that being frail was associated with poor cognitive performance, but the
authors considered the possibility that the phenomena occurred simultaneously. The first
study did not investigate the role of age and schooling in the association in question. In
a second study with the same sample, Macuco et al 1313 . Macuco CR, Batistoni SST, Lopes A, Cachioni M, Falcão DVS, Neri AL, et al.
Mini-Mental State Examination performance in frail, pre-frail, and non-frail community
dwelling older adults in Ermelino Matarazzo, São Paulo, Brazil. Int
Psychogeriatr . 2012;24(11):1725-31.
DOI:10.1017/S1041610212000907
https://doi.org/10.1017/S104161021200090...
showed that the MMSE score was influenced by age, education,
household income and being frail. Frail older elderly individuals performed significantly
worse in the MMSE.
This study aimed to analyze the association between frailty syndrome and cognitive performance in older individuals and the influence of schooling and age on this association.
METHODS
The data came from Stage 1 of the Estudo da Fragilidade em Idosos Brasileiros (Frailty in Brazilian Older People Study), Rio de Janeiro section (FIBRA-RJ), one of the research centers of the FIBRA Network. There were 847 individuals aged 65 and over who participated in this study. They were clients of a private health care plan, resident in the north of Rio de Janeiro, RJ, Southeastern Brazil, between January 2009 and January 2010.
To select the sample, stratification was carried out for sex versus age group of the clients registered in the private health care plan’s database. The age groups were defined as: 65 to 74; 75 to 84; 85 to 94; and 95 and over. In this last age group, there was no selection for the strata of men and women (all the individuals were included); the likelihood of selection was the same in the other strata. It was necessary to use an inverse random sampling strategy to attain the representative sample size for each stratum, ensured by replacing lost individuals due to no response, refusal and not being with the area of the study (living in a care home, change of direction or death occurring before the start of the study). The sample size was calculated so that the coefficient of variation of the different estimates for the variables in question in each stratum was 15% for estimates of proportion around 0.07, with 95% confidence interval. A factor of expansion was attributed to each sample unit, defined from a basic weight, and a factor of correction that combined the adjusts for non-response and for the situation including all of participants who died during the study and those who refused to take part.
The sample interviewed for the FIBRA-RJ consisted of 847 individuals, representing an expanded sample of 9,197 units of analysis. There were 737 individuals included in the analysis, after excluding 110 (12.9%) who did not complete the MMSE (12 individuals, 1.4%), for severe sensory deficit (52 individuals, 6.1%) and those whose walking speed could not be measured (27 individuals, 3.2%) as they were in a wheelchair or bedridden. A weighted and expanded sample of 8,085.65 was obtained considering the weight of each unit and of the exclusions.
The data were collected in face-to-face interviews, lasting approximately 60 min.
Cognitive performance was assessed using the MMSE. 33 . Brucki SMD, Nitrini R, Caramelli P, Bertolucci PHF, Okamoto IH. Sugestões
para o uso do mini-exame do estado mental no Brasil. Arq Neuropsiquiatr .
2003;61(3B):777-81. DOI:10.1590/S0004-282X2003000500014
https://doi.org/10.1590/S0004-282X200300...
,
55 . Folstein MF, Folstein SE, McHugh PR. “Mini-mental state”: a practical
method for grading the cognitive status of patients for the clinician. J Psychiatr
Res . 1975;12(3):189-98. DOI:10.1016/0022-3956(75)90026-6
https://doi.org/10.1016/0022-3956(75)900...
The cutoff points were 18/19 (poor
cognitive performance/normal cognitive performance) for illiterate subjects and 24/25 for
those with one or more years of studies. 1212 . Lourenço RA, Veras RP. Mini-Mental State Examination: psychometric
characteristics in elderly outpatients. Rev Saude Publica .
2006;40(4):712-9. DOI:10.1590/S0034-89102006000500023
https://doi.org/10.1590/S0034-8910200600...
The five items proposed by Fried et al 66 . 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;56(3):M146-57. DOI:10.1093/gerona/56.3.M146
https://doi.org/10.1093/gerona/56.3.M146...
were considered: unintentional weight loss; feeling of exhaustion; weak grip; low levels
of physical activity and slow walking pace. Older individuals with three or more of the
above characteristics were deemed frail. Older adults with one or two characteristics were
deemed pre-frail.
Unintentional weight loss was assessed using self-reporting. Subjects who had
unintentionally lost > 4.5 kg or > 5% of body weight within the last year or those
with a body mass index < 18.5 kg/m were considered positive. 22 . Boult L, Boult C, Pirie P, Pacala JT. Test-retest reliability of a
questionnaire that identifies elders at risk for hospital admission. J Am Geriatr
Soc . 1994;42(7):707-11.
,
66 . 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;56(3):M146-57. DOI:10.1093/gerona/56.3.M146
https://doi.org/10.1093/gerona/56.3.M146...
Feeling exhausted was assessed using two items from the Center of Epidemiological Study
Center Scale (CES-D): 1818 . Radloff LS. the CES-D Scale. Appl Psychol Meas .
1977;1(3):385-401. DOI:10.1177/014662167700100306
https://doi.org/10.1177/0146621677001003...
“Do you feel
like you have to make an effort to take care of your normal tasks?” and “Do you feel like
you can’t get going?”. For this item of frailty, subjects who answered “Yes” to at least
one of these questions were deemed positive. 66 . 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;56(3):M146-57. DOI:10.1093/gerona/56.3.M146
https://doi.org/10.1093/gerona/56.3.M146...
Grip strength was assessed using a hand dynamometer (JAMAR Modelo J00105) with the
dominant arm and asking the participant to squeeze as hard as possible, three times.
Subjects in the first quintile after adjusting for sex and body mass index 66 . 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;56(3):M146-57. DOI:10.1093/gerona/56.3.M146
https://doi.org/10.1093/gerona/56.3.M146...
were considered positive in this item of
frailty.
Levels of physical activity were assessed using the Minnesota Leisure Time, 2222 . Taylor HL, Jacobs Jr DR, Schucker B, Knudsen J, Leon AS, Debacker G. A
questionnaire for the assessment of leisure time physical activities. J Chronic
Dis . 1978;31(12):741-55. instrument that evaluates the physical
activity carried out by the subject and the estimated calories burned (per minute). The
calculation takes into consideration the individual’s body weight and the figure for the
metabolic equivalent (MET; 1 MET = 0.0175 kcal x kg-1 x min-1) needed to carry out the
activity. The quantity of MET needed for each activity is already known. 2222 . Taylor HL, Jacobs Jr DR, Schucker B, Knudsen J, Leon AS, Debacker G. A
questionnaire for the assessment of leisure time physical activities. J Chronic
Dis . 1978;31(12):741-55. The subjects in the first quintile were
considered positive for this item. 66 . 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;56(3):M146-57. DOI:10.1093/gerona/56.3.M146
https://doi.org/10.1093/gerona/56.3.M146...
Slow walking pace was evaluated using a chronometer to measure the time needed to walk
4.5m. Subjects in the first quintile after adjusting for height were considered positive.
66 . 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;56(3):M146-57. DOI:10.1093/gerona/56.3.M146
https://doi.org/10.1093/gerona/56.3.M146...
Socio-economic and demographic characteristics included gender, age, schooling (in years
of study), marital status and personal income (in minimum wages). Medical conditions were
assessed using the following questions: “In the last year, have you been told by a doctor
that you have any of the following health problems: heart disease such as angina,
myocardial infarction or heart attack, hypertension, vascular stroke/stroke/cerebral
ischemia, diabetes mellitus, arthritis or rheumatism, or depression?”. The following
question was asked in order to assess urinary and fecal incontinence: “In the last 12
months have you suffered from any of these problems?” Functional capacity was evaluated
using the instrumental (IADL) 1111 . Lawton MP, Brody EM. Assessment of older people: self-maintaining and
instrumental activities of daily living. Gerontologist . 1969;9(3 Part
1):179-86. DOI:10.1093/geront/9.3_Part_1.179
https://doi.org/10.1093/geront/9.3_Part_...
and
basic (BADL) 99 . Katz S, Ford AB, Moskowitz RW, Jackson BA, Jaffe MW. Studies of illness in
the aged. The index of ADL: a standardized measure of biological and psychosocial
function. JAMA ;1963;185(12):914-9.
DOI:10.1001/jama.1963.03060120024016
https://doi.org/10.1001/jama.1963.030601...
activities of daily living
scales. Those who declared themselves capable of carrying out all of the basic and
instrumental activities without any help were classified as independent, whereas those who
reported themselves incapable of performing one or more of the basic and/or instrumental
activities were deemed to be dependent.
The weightings for each individual were considered in all of the analyses, as this was a
weighted, expanded sample. The cognitive performance variable (MMSE) was treated as
dichotomous, 1212 . Lourenço RA, Veras RP. Mini-Mental State Examination: psychometric
characteristics in elderly outpatients. Rev Saude Publica .
2006;40(4):712-9. DOI:10.1590/S0034-89102006000500023
https://doi.org/10.1590/S0034-8910200600...
as was being frail (Not
frail/Pre-frail and Frail). The association between frailty and the co-variables and
cognitive performance was assessed. Pearson’s Chi-square test was used for bivariate
analysis. The Mantel Haenszel interaction test was used to verify whether the variables of
age and schooling acted as effect modifiers on the association between frailty and poor
cognitive performance. Next, multivariate logistic regression was carried out to assess
the effect of being frail on cognitive performance, after adjusting for confounding
variables. Raw and adjusted odds ratios and their respective 95% confidence intervals were
calculated. The co-variables that showed simple association with the outcome (p ≤ 0.25)
were included in the models as confounding variables. These analyses were stratified by
age group (65 to 74, 75 to 84 and 85 and over). The data were analyzed using the SPSS
statistics program version 18.
The study was approved by the Research Ethics Committee of the Hospital Universitário Pedro Ernesto (Process nº 1850-CEP/HUPE, 2007). All participants signed a consent form.
RESULTS
There 737 older adults aged between 65 and 101 years (mean 76.7 years) who were analyzed. The prevalence of frailty was 9.2%; 46.5% of the individuals were deemed to be pre-frail. The prevalence of poor cognitive performance was 30.2%. Most individuals were female (66.9%) and were aged between 65 and 84 (40.9% from 65 to 74 and 46.4% from 75 to 84), and 0.6% were aged over 95. The percentage of individuals with nine or more years of study was high compared with national patterns: 31.8% had between nine and 12 years of study and 28.4% had 13 or more. Individuals with between five and eight years of schooling made up 20.3% of the total; two to four years, 16.5%; and zero to one year, 2.9%. Most older adults in this sample were married or cohabiting (44.0%) and a significant percentage were widowed (37.7%). The most common income was between 2.1 and five minimum wages (34.5%) and was similar in all other income bands: 27.5% of individuals received over eight minimum wages; 21.7% between 5.1 and eight; and 16.4% between zero and two minimum wages. The majority (87.4%) received support from a network of social relationships and a large part of the sample had some type of functional dependency (56.5%). The following rates of prevalence of morbidities were found: 64.6% for hypertension, 34.9% for arthritis or osteoarthritis, 22.2% diabetes mellitus, 21.4% for urinary incontinence, 13.8% for coronary artery disease, 13.4% for depression, 5.6% for fecal incontinence and 4.4% for cerebrovascular accident (CVA).
There was a statistically significant difference in cognitive performance with regards all of the socio-economic and demographic variables. The highest prevalence of poor cognitive performance was observed in females, those of advanced age, with low levels of schooling and on a low income ( Table 1 ).
Higher prevalence of poor cognitive performance was found in older adults who had suffered CVA at some point in their lives, those who were depressed, those with arthritis or osteoarthritis, those with urinary incontinence and those who were functionally dependent. There was a statistically significant difference with regards having suffered from a CVA, depression, arthritis or osteoarthritis, urinary incontinence and being functionally dependent. Having someone to care for them if necessary, having coronary artery disease, hypertension, diabetes mellitus, suffering from or having suffered from cancer and fecal incontinence did not any statistically significant difference ( Table 2 ).
Age, according to the different age groups, acted as an effect modifier (Mantel Haenszel, χ2(5) = 806.97, p < 0.0001) for the association between frailty and poor cognitive performance. No modification of effect was observed between frailty and poor cognitive performance according to different levels of schooling (from zero to eight years and more than eight years).
After adjusting for the physical morbidity variables (CVA, depression, urinary incontinence, arthritis or osteoarthritis) and the activities of daily life and socio-economic and demographic variables, which remained in the final model, the association between frailty and poor cognitive performance remained in those older individuals aged 75 and over (OR = 2.78; 95%CI 1.23;6.27) those aged 75 to 84 and OR = 15.62; 95%CI 2.20;110.99 for those 85 and over ( Table 3 ).
DISCUSSION
The results of this study confirm the association between frailty and poor cognitive
performance found in other studies 44 . Buchman AS, Boyle PA, Wilson RS, Tang Y, Bennett DA. Frailty is associated
with incident Alzheimer’s disease and cognitive decline in the elderly. Psychosom
Med . 2007;69(5):483-9. DOI:10.1097/psy.0b013e318068de1d
https://doi.org/10.1097/psy.0b013e318068...
,
1313 . Macuco CR, Batistoni SST, Lopes A, Cachioni M, Falcão DVS, Neri AL, et al.
Mini-Mental State Examination performance in frail, pre-frail, and non-frail community
dwelling older adults in Ermelino Matarazzo, São Paulo, Brazil. Int
Psychogeriatr . 2012;24(11):1725-31.
DOI:10.1017/S1041610212000907
https://doi.org/10.1017/S104161021200090...
,
2020 . Samper-Ternent R, Al Snih S, Raji MA, Markides KS, Ottenbacher KJ.
Relationship between frailty and cognitive decline in older Mexican Americans. J
Am Geriatr Soc . 2008;56(10):1845-52.
DOI:10.1111/j.1532-5415.2008.01947.x
https://doi.org/10.1111/j.1532-5415.2008...
and gives a result previously
unreported in the literature on the topic: the role of age as an effect modifier in this
association.
Although comparisons between these results and others described previously 44 . Buchman AS, Boyle PA, Wilson RS, Tang Y, Bennett DA. Frailty is associated
with incident Alzheimer’s disease and cognitive decline in the elderly. Psychosom
Med . 2007;69(5):483-9. DOI:10.1097/psy.0b013e318068de1d
https://doi.org/10.1097/psy.0b013e318068...
,
2020 . Samper-Ternent R, Al Snih S, Raji MA, Markides KS, Ottenbacher KJ.
Relationship between frailty and cognitive decline in older Mexican Americans. J
Am Geriatr Soc . 2008;56(10):1845-52.
DOI:10.1111/j.1532-5415.2008.01947.x
https://doi.org/10.1111/j.1532-5415.2008...
are limited due to difference in
sample design and population, they point in the same direction, i.e., they reinforce the
evidence of the association between frailty and poor cognitive performance. Samper-Ternent
et al 2020 . Samper-Ternent R, Al Snih S, Raji MA, Markides KS, Ottenbacher KJ.
Relationship between frailty and cognitive decline in older Mexican Americans. J
Am Geriatr Soc . 2008;56(10):1845-52.
DOI:10.1111/j.1532-5415.2008.01947.x
https://doi.org/10.1111/j.1532-5415.2008...
found lower MMSE scores among
the frail compared with those who were not frail. The risk of a frail older adult
obtaining a MMSE score below 21 was 1.3 times higher than for a non-frail counterpart
after ten years of follow up and adjusting for all of the co-variables (gender, age group,
schooling, marital status and medical conditions). Another study with 820 subjects,
assessed over three years, found that the risk of developing Alzheimer’s was 2.5 times
greater among frail individuals. 44 . Buchman AS, Boyle PA, Wilson RS, Tang Y, Bennett DA. Frailty is associated
with incident Alzheimer’s disease and cognitive decline in the elderly. Psychosom
Med . 2007;69(5):483-9. DOI:10.1097/psy.0b013e318068de1d
https://doi.org/10.1097/psy.0b013e318068...
Studies in Brazil have shown poorer cognitive performance in frail older adults than those
who were pre-frail or normal. 2424 . Yassuda MS, Lopes A, Cachioni M, Falcão DV, Batistoni SS, Guimarães VV, et
al. Frailty criteria and cognitive performance are related: data from the FIBRA study in
Ermelino Matarazzo, São Paulo, Brazil. J Nutr Health Aging .
2012;16(1):55-61. In
addition to being frail, increased age, low levels of schooling and low household income
were associated with worse scores for overall cognitive performance, for temporal
orientation and for short-term memory. 1313 . Macuco CR, Batistoni SST, Lopes A, Cachioni M, Falcão DVS, Neri AL, et al.
Mini-Mental State Examination performance in frail, pre-frail, and non-frail community
dwelling older adults in Ermelino Matarazzo, São Paulo, Brazil. Int
Psychogeriatr . 2012;24(11):1725-31.
DOI:10.1017/S1041610212000907
https://doi.org/10.1017/S104161021200090...
None of these studies assessed the role played by age an effect
modifier on the association between frailty and poor cognitive performance. This variable
was tested only as a confounding factor with regards frailty and cognition.
Researchers in the area support the idea of adding loss of cognitive function as one of
the components of frailty, although this is a controversial issue. For now, it is
recommended that frail patients undergo assessment of cognitive functions and that frailty
be investigated in those with loss of cognitive function. 2020 . Samper-Ternent R, Al Snih S, Raji MA, Markides KS, Ottenbacher KJ.
Relationship between frailty and cognitive decline in older Mexican Americans. J
Am Geriatr Soc . 2008;56(10):1845-52.
DOI:10.1111/j.1532-5415.2008.01947.x
https://doi.org/10.1111/j.1532-5415.2008...
The primary finding of this study is the evidence of the role age plays in the association in question. Multivariate analysis, stratified by age group (65 to 74, 75 to 84 and 85 and over) is adjusted for physical morbidities and socio-economic and demographic variables, showing that this association persists in those aged over 75 and that the chance of a frail older adult having poor cognitive performance is around seven times greater in those aged 85 and over than in those aged between 75 and 84. The test for interaction between frailty and age was statistically significant (p < 0.0001).
Frailty was more prevalent in older age groups. 66 . 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;56(3):M146-57. DOI:10.1093/gerona/56.3.M146
https://doi.org/10.1093/gerona/56.3.M146...
Physiological changes in the brain due to increased age, which
may lead to significant cognitive alterations, are also described. 1414 . Mesulam M. Aging, Alzheimer`s disease, and dementia: clinical and
neurobiological perspectives. In: Mesulam M, editor. Principles of behavioral and
cognitive neurology. 2.ed. Oxford: Oxford University Press; 2000.
p.439-522. Thus, it is possible to understand in what way age may
act as an effect modifier in the association between frailty and cognitive
performance.
The hypothesis that schooling would be an effect modifier in the association in question
was not confirmed in the analyses. The results of other studies on performance in
neuro-psychological tests state that low levels of schooling can interfere with test
scores. 11 . Bertolucci PHF, Brucki SMD, Campacci SR, Juliano Y. O Mini-Exame do Estado
Mental em uma população geral: impacto da escolaridade. Arq
Neuropsiquiatr . 1994;52(1):1-7.
DOI:10.1590/S0004-282X1994000100001
https://doi.org/10.1590/S0004-282X199400...
,
1212 . Lourenço RA, Veras RP. Mini-Mental State Examination: psychometric
characteristics in elderly outpatients. Rev Saude Publica .
2006;40(4):712-9. DOI:10.1590/S0034-89102006000500023
https://doi.org/10.1590/S0034-8910200600...
Despite there being no relationship between schooling and frailty established in the
literature, it is plausible that the level of education acts as an effect modifier in the
association between frailty and cognitive performance by mechanisms such as cognitive
reserve, 2121 . Stern Y. Cognitive reserve. Neuropsychologia .
2009;47(10):2015-28. DOI:10.1016/j.neuropsychologia.2009.03.004
https://doi.org/10.1016/j.neuropsycholog...
in which increased levels of
schooling are viewed as protection against genitive damage in older individuals. However,
no other study investigating the role of schooling in the association in question was
found.
The main limitations of this study were the use of only one screening test to assess cognition, when the ideal would be to use a short battery of neuro-psychological tests. The MMSE gives an overall assessment of cognition; though it would be interesting to consider the different cognitive functions (memory, executive function, attention, language and others) separately in the association between frailty and cognitive performance. Moreover, a more complete cognitive assessment would give more precise data on the prevalence of poor cognitive performance. Another limitation lies in the cross-sectional design, which does not allow the order in which the phenomenon occur to be known, and may lead to reverse causality. This possibility should not be ruled out, considering that the phenomena in question work both ways. A longitudinal study of older adults without cognitive loss would allow its incidence in frail and non-frail older adults to be assessed and enable the calculation of relative risk of this decline associated with frailty.
The association between frailty and cognition in the ageing remains a topic little studied nationally and internationally. This investigation was pioneering in assessing the role of age and schooling as potential effect modifiers in the association in question. Frailty decreases cognitive performance in individuals aged 75 and over, possibly due to mechanisms such as decreases in cognitive and physiological reserves suffered by those aged over 85. Such findings indicate the need for specialized assessments of the population aged 74 and over and who are frail. Longitudinal studies of the Brazilian population need to be carried out to assess the role frailty plays in changes in cognitive performance in the older adults over time. The use of other neuro-psychological tests might contribute to more specific assessments of cognitive performance and all the start of the decline to be identified, which is fundamental to determining incidence.
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a
Instituto Brasileiro de Geografia e Estatística. Indicadores sociodemográficos e de saúde no Brasil 2009. Rio de Janeiro; 2009. (Estudos e Pesquisas. Informações Demográficas e Socioeconômicas, 25).
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Instituto Brasileiro de Geografia e Estatística. Projeção da população do Brasil por sexo e idade para o período 1980-2050: revisão 2008. Rio de Janeiro; 2009. (Estudos e Pesquisas. Informações Demográficas e Socioeconômicas, 24).
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Article based on the masters dissertation of Faria C.A., entitled “Cognitive performance and frailty in elderly clients of a health care provider”, presented to the Post-Graduate Program in Public Health, Department of Epidemiology, Instituto de Medicina Social, Universidade do Estado do Rio de Janeiro, in 2011.
Publication Dates
-
Publication in this collection
Oct 2013
History
-
Received
2 July 2012 -
Accepted
24 June 2013