Frailty is associated with sociodemographic and health factors and related to the care context of older caregivers: a Brazilian cross-sectional study

Abstract BACKGROUND: The task of caring can arise suddenly without guidance or support, resulting in psychological tension and health impairment, which can culminate in the development of frailty. OBJECTIVE: To analyze the relationship between frailty and sociodemographic and health aspects related to the care context of older caregivers. DESIGN AND SETTING: A cross-sectional study was conducted on 65 older caregivers registered in family health units in the interior of the state of São Paulo. METHODS: The participants were interviewed individually using the following instruments: a characterization questionnaire, Fried’s frailty phenotype, Zarit Burden’s Interview, Mini-Mental State Examination, Geriatric Depression Scale, Katz Index, and Lawton Scale. In addition, the following statistical tests were applied: Pearson’s chi-squared test, Fisher’s exact test, and Mann–Whitney test. A significance level of 5% was considered to be statistically significant. RESULTS: Women who took care of their spouses predominated without prior training or the help of other people. Most of the patients were pre-frail (72.3%). Frailty was significantly related to marital status (P = 0.016), depressive symptoms (P = 0.029), cognitive decline (P = 0.029), the degree of kinship (P = 0.015), and burden (P = 0.004). CONCLUSION: Older caregivers without a partner, with severe depressive symptoms and cognitive changes, who cared for their parents, and had higher levels of burden, presented a higher proportion of frailty.

burden did not increase the chances of frailty among older caregivers. 4 A cross-sectional study was conducted in São Carlos with 328 older caregivers from the community, which identified that 58.8% of the participants were pre-frail, and 21.1% were frail. Frailty was associated with advanced age, female sex, depressive symptoms, pain, and the absence of a partner. 5 There are little data available in the literature on frailty syndrome in older adult caregivers and its relationship with the care context. 5 Therefore, it is necessary to investigate it, considering that older adult caregivers with advanced age may present a higher risk of frailty 4 because they face aging, health problems, and increasing demands related to the care process. 5 Furthermore, in view of the above, it is relevant to know the relationship between frailty and sociodemographic and health aspects related to the care context of older caregivers, especially in poverty, since the presence of this syndrome may impair both the quality of life and well-being of these individuals.

OBJECTIVE
To analyze the relationship between frailty and sociodemographic and health aspects related to the care context of older caregivers.

Design, period, and place of study
It is an observational, cross-sectional, quantitative research, part were included.

Criteria of inclusion and exclusion
The study included all the older caregivers who met the following inclusion criteria: 60 years of age or older; being the primary caregiver of an older adult; being a relative of the older in care, who was dependent on at least one basic activity (BADL, evaluated using the Katz Index) or instrumental activities of daily liv- To evaluate frailty in older caregivers, the study adopted the phenotype proposed by Linda Fried based on five elements: 1. Unintentional weight loss -"Do you think you have lost weight without dieting in the last 12 months?" If yes, if this weight loss was equal to or greater than 4.5 kg or 5% of body weight in the previous year, the older adults scored this criterion.
2. Fatigue -"How often did you feel that everything you did required a lot of effort in the last week"? and "How often did you feel that you could not carry on with your things in the last week"?
The older adults who answered "always" or "most of the time" for either of these two questions scored on this criterion.
3. Low palmar grip strength: The researchers measured it using a portable hydraulic dynamometer in the dominant hand.
They performed three consecutive measurements of palmar grip strength using the arithmetic mean. Then, the results were adjusted to complete the criteria according to sex and body mass index (BMI).
4. Low level of caloric expenditure: adapted question. It was assessed by self-report based on the following question: "Do you think you perform less physical activity than you did 12 months ago?" If so, older adults scored this criterion. Finally, we used it to calculate the sum of the scores obtained.
A score between 0 and 5 points indicates an absence of depressive symptoms, 6 to 10 points indicate mild depressive symptoms, and 11 to 15 points indicate severe depressive symptoms. 12

Ethical aspects
The study followed all the ethical aspects contained in Resolution

Analysis of results and statistics
The Kolmogorov-Smirnov test was used to verify the normality of the variables. It helped to estimate the frequency distributions, means, and minimum and maximum values for the numerical variables of the study for descriptive analysis of the data.
The proportions of categorical variables were also estimated.
Pearson's chi-square, Fisher's exact, and Mann-Whitney tests were used to identify differences between the groups. Pearson's chi-square test or Fisher's exact test was used to compare categorical variables, which were sociodemographic and health charac-

RESULTS
The study sample consisted of 65 older caregivers. Of these, 72.3% were pre-frail, 24.6% were frail, and 3.1% were robust. Regarding frailty criteria, reduction in physical activity was the most prevalent component (75.4%), followed by fatigue (38.5%), weakness (35.4%), weight loss (24.6%), and slow gait (21.5%). Table 1 presents the sociodemographic characteristics of the older caregivers in the context of high social vulnerability according to frailty.
The proportion of frailty was higher among older caregivers who did not have a partner than among those with a partner (P = 0.016). Table 2 presents the health characteristics of older caregivers in the context of high social vulnerability according to frailty.
The study indicated that the proportion of frailty was higher among older caregivers with severe depressive symptoms when compared with that of the others (P = 0.029). Statistically significant differences were also identified between cognitive decline and frailty (P = 0.029). Among older caregivers with cognitive changes, the percentage of frailty was higher when compared with that of older adults without cognitive impairment. Table 3 presents the characteristics related to the care conditions of older caregivers in the context of high social vulnerability according to frailty.
The results showed that the proportion of frailty was higher among older adults who cared for their parents when compared with that of other categories (P = 0.015). Moreover, the majority of the older caregivers who scored for the absent or moderate burden were not frail, while older caregivers who scored for moderate to severe or severe burns were frail (P = 0.004).

DISCUSSION
Older pre-frail caregivers were predominant (72.3%), followed by frail caregivers (24.6%). Although they present different proportions, it also identified a higher prevalence of pre-frailty in a national survey conducted with caregivers of older adults from São Paulo municipalities. 1 This divergence in proportion may have occurred because of the use of different instruments to assess frailty. An international study also observed a predominance of older pre-frail caregivers. 4 Being an older caregiver may favor their entry into the cycle of frailty because of the greater exposure to stressors due to aging associated with the presence of morbidities. In addition, the older caregiver undergoes intense changes in their daily routine that can negatively reflect their physical and psychological health, making them more vulnerable to adversity, which would facilitate the installation of the syndrome. 5 Researchers point out that the risk of an older caregiver becoming frail may be partially related to the lower propensity of these caregivers to engage in preventive health behaviors. 4 The present study found that older caregivers who did not have a partner had a higher proportion of frailty. A case-control study conducted in Belgium showed divergent data. 4 However, a national investigation conducted with 328 older caregivers identified that participants without partners had 11.03 and 14.39 times more chances of developing pre-frailty and frailty, respectively, when compared with those with partners. 5 According to the literature, being married is a positive condition for general health. Evidence shows that having a partner raises the feeling of well-being, works as a protective factor against loneliness, and exposes the couple to healthier lifestyle habits, which are extremely important for physical, mental, and cognitive maintenance. Therefore, older adults without a partner can become frail due to insufficient physical activity and food inadequacy, which are factors that contribute to sarcopenia. 13 In the present study, the proportion of frailty was higher among older caregivers with severe depressive symptoms. The data we found corroborate those of other investigations. 5,[13][14][15] Scholars state that older adult caregivers may manifest more depressive symptoms than non-caregivers and that a possible explanation would be the high demand for care and emotional pressure derived from the solitary performance of the task of caring. 16  There is also controversy among researchers regarding the inclusion of cognitive impairment as one of the criteria for frailty, 19 given that both conditions are multifactorial, have a higher incidence in older adults, and seem to share similar pathophysiological mechanisms. In addition, female sex, low education, and sedentary lifestyle are possible risk predictors for both conditions. 20 From this perspective, the context of high social vulnerability can be configured as a risk factor for older caregivers because the profile of these individuals reveals low education, financial and support scarcity, greater exposure to psychosocial stressors, and low adherence to the treatment of diseases, as well as physical and cognitive impairments. 21 Thus, cognitive impairment due to physical conditions has the potential for reversibility. Therefore, the sooner interventions are identified, the more effective they may be. 22 Older adults who cared for their parents presented a higher percentage of frailty than that of the others. Scholars point out that the responsibility of care can be considered an obligation, given that parents have previously devoted care to their children. 23 Thus, the feeling of obligation combined with uninterrupted care could trigger symptoms of exhaustion and lack of time for oneself, discouraging older adults from performing leisure activities and increasing the possibility of falling within the criteria of the phenotype. 5 This explanation is in line with the context of care in the present study.
In the present study, most older caregivers who scored little or moderate burden were not frail, while most of those who scored moderate to severe or severe burden were frail. These findings confirm the results of a national study. 1,14 Assuming the role of caregiver of another older adult requires a high degree of vigilance and attention, which can generate physical and psychological tension over time, especially in the face of unpredictable situations and the lack of social support. 1 In addition, cohabiting with the recipient of care exposes the caregiver to continuous and uninterrupted demand, favoring low insertion in social, physical, and leisure activities. 21 Such conditions interact with each other, leading to the entry of older adults into the cycle of frailty.
Frailty syndrome results from a series of changes in biological mechanisms that culminate in the deregulation of multiple systems and, consequently, in homeostatic imbalance. Therefore, the body cannot tolerate stressors in the face of the reduced available energy, which triggers a progressive decline in physical functioning, 24 contributing to the individual feeling overwhelmed. In contrast, burns can also cause homeostatic imbalance and favor the occurrence of frailty, considering that, in the care context, there are high demands and an excess of tasks that need to be performed.
It could generate a feeling of fatigue and exhaustion in addition to the short time for self-care, which would contribute to physical inactivity, a known path to the cycle of frailty. Thus, this explanation route has a double meaning; that is, a weakened organism may have a more impactful view of the care context, leading to a higher perception of burden, just as a burdened individual may present dysfunction of multiple systems and become frail.
In the face of such reflections, this study suggests that primary healthcare professionals should develop psychosocial and psychoeducational actions that aim to reduce the impact of tension involved in the task of care. Therefore, group interventions can contribute to the exchange of experiences, stimulate social interaction, and offer support to caregivers inserted in this context 25 since the absence of support and education can subject the older caregiver to the worsening of already installed morbid conditions.
Integrating health promotion and disease prevention behaviors can prevent the burden from being added to other occurrences, thus reducing the chances of the caregiver becoming frail and presenting unfavorable health outcomes, such as falls, early institutionalization, hospitalization, and death. 1 The study recommends the The present study has some limitations. The cross-sectional design did not allow us to assign causality between variables. In addition, the small sample size and the specific context of the social vulnerability of older caregivers limit the generalization of the findings.

CONCLUSION
Older caregivers without a partner, with severe depressive symptoms and cognitive changes, who cared for their parents, and had higher levels of burden, presented a higher proportion of frailty.