CLINICAL-FUNCTIONAL VULNERABILITY IN OLDER ADULTS: A MIXED-METHODS STUDY IN PRIMARY HEALTH CARE

Both, Caroline Thaís; Leite, Marinês Tambara; Cechinel-Peiter, Caroline; Moura, Leticia de; Erdmann, Alacoque Lorenzini

doi:10.1590/1980-265X-TCE-2025-0098en

ABSTRACT

Objective: To analyze self-perception and the aspects associated with clinical-functional vulnerability in older adults linked to Primary Health Care.

Method: A mixed-methods study with an explanatory sequential design (QUAN→qual), conducted with older adults using Primary Health Care services in a rural municipality in the state of Rio Grande do Sul, Brazil. Data were collected between January and August 2023, using an instrument with questions on sociodemographic characteristics and health conditions, the Clinical-Functional Vulnerability Index (IVCF-20), and semi-structured interviews. The quantitative stage included a sample of 356 older adults, while the qualitative stage reached data saturation with 22 interviews. Quantitative data were analyzed using descriptive and inferential statistics, including Pearson's chi-square and Kruskal-Wallis tests. Qualitative data were analyzed using thematic analysis. Data mixing was performed through connecting integration and is presented as a joint display. All ethical principles were respected.

Results: The mean age of the sample was 71.3 years, and most participants were women with low educational attainment. Clinical-functional vulnerability was low risk in 54.2% of participants, while 45.8% presented moderate to high risk. Older adults' self-perception revealed experiences of frailty, physical and emotional limitations, insecurity, and increasing dependence. These findings indicate the interdependent and multidimensional nature of clinical-functional vulnerability.

Conclusion: Clinical-functional vulnerability in older adults reflects a complex and vicious cycle of limitations that compromise functional capacity, requiring multidisciplinary interventions that promote clinical support, functional rehabilitation, and social inclusion.

DESCRIPTORS:
Older adult; Frail elderly; Functional status; Primary Health Care; Geriatric assessment; Nursing

RESUMO

Objetivo: analisar a autopercepção e os aspectos associados à vulnerabilidade clínico-funcional em pessoas idosas vinculadas à Atenção Primária à Saúde.

Método: pesquisa de métodos mistos, com abordagem sequencial explanatória (QUAN→qual), realizada com idosos usuários da Atenção Primária à Saúde de um município rural, no estado do Rio Grande do Sul, Brasil. A coleta dos dados ocorreu entre janeiro e agosto de 2023, com uso de instrumento com questões de caracterização sociodemográfica e das condições de saúde, Índice de Vulnerabilidade Clínico-Funcional (IVCF-20) e entrevistas semiestruturadas. A etapa quantitativa foi composta por uma amostra de 356 pessoas idosas, enquanto na qualitativa alcançou-se a saturação de dados com 22 entrevistas. Os dados quantitativos foram analisados por análise descritiva e probabilística, com testes qui-quadrado de Pearson e de Kruskal-Wallis. Os qualitativos seguiram a análise temática. Realizou-se a mixagem dos dados por integração por conexão, apresentando-a em forma de joint display. Respeitaram-se todos os preceitos éticos.

Resultados: A idade média da amostra foi de 71,3 anos, e a maioria eram mulheres e com reduzida escolaridade. A vulnerabilidade clínico-funcional de 54,2% dos participantes foi de baixo risco, e 45,8% deles apresentaram risco moderado a alto. A autopercepção das pessoas idosas revelou vivências de fragilidade, limitações físicas e emocionais, insegurança e dependência crescente. Assim, evidencia-se o caráter interdependente e multidimensional da vulnerabilidade clínico-funcional.

Conclusão: A vulnerabilidade clínico-funcional em pessoas idosas reflete um ciclo complexo e vicioso de limitações que comprometem a capacidade funcional, exigindo intervenções multidisciplinares que promovam suporte clínico, reabilitação funcional e inclusão social.

DESCRITORES:
Idoso; Idoso fragilizado; Estado funcional; Atenção Primária à Saúde; Avaliação geriátrica; Enfermagem

RESUMEN

Objetivo: analizar la autopercepción y los aspectos asociados a la vulnerabilidad clínico-funcional en personas mayores vinculadas a la Atención Primaria de Salud.

Método: investigación de métodos mixtos, con abordaje secuencial explicativo (QUAN→qual), realizada con personas mayores usuarias de la Atención Primaria de Salud de un municipio rural, en el estado de Rio Grande do Sul, Brasil. La recolección de datos se realizó entre enero y agosto de 2023, mediante un instrumento con preguntas de caracterización sociodemográfica y de las condiciones de salud, el Índice de Vulnerabilidad Clínico-Funcional (IVCF-20) y entrevistas semiestructuradas. La etapa cuantitativa estuvo compuesta por una muestra de 356 personas mayores, mientras que en la cualitativa se alcanzó la saturación de datos con 22 entrevistas. Los datos cuantitativos fueron analizados mediante análisis descriptivo y probabilístico, con las pruebas de chi-cuadrado de Pearson y de Kruskal-Wallis. Los datos cualitativos siguieron el análisis temático. Se realizó la mixtura de los datos por integración por conexión, presentándola en forma de joint display. Se respetaron todos los preceptos éticos.

Resultados: La edad media de la muestra fue de 71,3 años, y la mayoría eran mujeres y con baja escolaridad. La vulnerabilidad clínico-funcional del 54,2% de los participantes fue de bajo riesgo, y el 45,8% de ellos presentó riesgo moderado a alto. La autopercepción de las personas mayores reveló vivencias de fragilidad, limitaciones físicas y emocionales, inseguridad y dependencia creciente. Así, se evidencia el carácter interdependiente y multidimensional de la vulnerabilidad clínico-funcional.

Conclusión: La vulnerabilidad clínico-funcional en las personas mayores refleja un ciclo complejo y vicioso de limitaciones que comprometen la capacidad funcional, exigiendo intervenciones multidisciplinarias que promuevan el apoyo clínico, la rehabilitación funcional y la inclusión social.

DESCRIPTORES:
Anciano; Anciano frágil; Estado funcional; Atención Primaria de Salud; Evaluación geriátrica; Enfermería

INTRODUCTION

Population aging is a worldwide phenomenon, but in Latin America and the Caribbean this transition is occurring at an even faster pace. This scenario poses significant challenges, particularly regarding access to essential basic resources, especially social and health resources, to ensure a dignified life in old age and active participation in society¹, indicating the need for effective public policies aimed at this growing segment of the population.

Increasing life expectancy and population aging have transformed the disease profile, with noncommunicable chronic diseases becoming increasingly prevalent. These conditions, associated with the natural aging process, tend to reduce clinical-functional capacity, making older adults more vulnerable to health complications, dependence, and disability²^,³.

Clinical-functional vulnerability involves organic changes that can affect various aspects of functioning, resulting in locomotor deficits, mood disorders, cognitive impairment, and communication difficulties. These factors compromise autonomy and independence in performing basic and instrumental activities of daily living⁴. When older adults are in a state of clinical-functional vulnerability, there is an increased risk of adverse outcomes, including the development of chronic and acute conditions, hospitalization, institutionalization, and death⁵.

In this context, assessing the clinical and functional status of older adults becomes relevant to design interventions and enable the provision of care appropriate to individual needs⁶. In addition to identifying older adults at greater risk of clinical-functional vulnerability, it is essential to understand how they perceive its impacts on daily life, considering their needs and limitations, to jointly develop a singular therapeutic plan with the best care practices. This topic is therefore aligned with the principles of equity and comprehensiveness of care in Primary Health Care (PHC)⁷, the Política Nacional de Saúde da Pessoa Idosa (National Policy for the Health of Older Adults)⁸, the Decade of Healthy Ageing¹ and the Sustainable Development Goals⁹, specifically those addressing the promotion of health and well-being for all people and the reduction of inequalities.

Notably, most studies conducted on this topic are cross-sectional³^,⁵^,⁶^,¹⁰^,¹¹, indicating the importance of conducting studies that also address subjective aspects, such as mixed-methods studies. This type of design makes it possible to broaden and deepen more complex topics¹², including the clinical-functional vulnerability of older adults. When the risk of clinical-functional vulnerability of older adults is stratified within the health care network, it becomes possible to propose individualized preventive, health-promoting, palliative, or rehabilitative interventions, according to the older adult's clinical-functional stratum and the functional domains affected¹³.

Considering this context, the present study aimed to analyze self-perception and the aspects associated with clinical-functional vulnerability in older adults linked to PHC.

METHODS

This study adopted a mixed-methods approach, with an explanatory sequential design (QUAN→qual), in which quantitative data were collected and analyzed first, followed by qualitative data¹⁴. The criteria established by the Mixed Methods Appraisal Tool were used to present the integration of data in the mixed-methods study¹². For reporting quality, the recommendations of the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) were followed for the quantitative analyses¹⁵, and the Consolidated Criteria for Reporting Qualitative Research (COREQ) were followed for the qualitative analyses¹⁶.

This study was conducted with community-dwelling older adults linked to PHC in a rural municipality located in the northwestern region of the state of Rio Grande do Sul, Brazil. The municipality had an estimated population of 8,010 inhabitants, of whom 1,869 (23.3%) were older adults. The inclusion criteria were being 60 years of age or older and being registered with the municipality's PHC service. The exclusion criterion was the presence of conditions that prevented participants from taking part in the interview or responding to the data collection instruments.

The quantitative stage used a cross-sectional, descriptive, and analytical design. The sample size was calculated assuming a 95% confidence level and a 5% margin of error, with an additional 10% added to compensate for potential losses. The eligible sample therefore comprised 356 older adults. With authorization from the Municipal Health Department, access was obtained to the list of individuals 60 years of age or older registered with the municipality's PHC service. Potential participants were then selected through a random draw using an online randomizer. Whenever an older adult declined to participate, a new draw was conducted until the expected sample size was reached.

In this stage, two instruments were administered: one containing questions on sociodemographic characteristics and health conditions, and the Clinical-Functional Vulnerability Index (IVCF-20) for screening.

The sociodemographic instrument included the following variables: age (in years), sex (male or female), self-reported race/color (White, Mixed-race, Black, Asian, Indigenous, or other), educational level, marital status (single, married, cohabiting, divorced, or widowed), religious affiliation (Catholic, Evangelical, or other), retirement status (yes or no), monthly income (no income, up to one minimum wage, more than 1 and up to 2 minimum wages, more than 2 and up to 4 minimum wages, more than 4 minimum wages), place of residence (urban or rural), number of people living in the same household, cohabitation (child, grandchild, other), number of children, self-rated health (poor, fair, good, or excellent), and medication use (one to three types of medication, three to six types, or more than six types).

The IVCF-20 is a validated¹⁷ Brazilian instrument for the rapid screening of clinical-functional vulnerability for use in PHC. It consists of 20 questions assessing the main predictive dimensions: age, self-perceived health, basic and instrumental activities of daily living, cognition, mood, mobility, communication, and multiple comorbidities. Each item has a specific score, with a maximum total of 40 points. The strata suggested by the IVCF-20 classify the degree of clinical-functional vulnerability as follows: 0 to 6 points, low risk; 7 to 14 points, moderate risk; and 15 or more points, high risk¹⁸.

In this stage, data were collected between January and June 2023 through individual interviews conducted either at the participant's home or at the health unit, at a date, time, and location previously agreed upon with the older adult. Participant identification and recruitment were facilitated by Community Health Workers, who were trained in questionnaire administration and assisted with data collection. This phase of the study began only after participants provided written informed consent by signing the consent form.

Quantitative data were entered into a Microsoft Excel® spreadsheet and analyzed using descriptive and inferential statistics. Categorical variables were summarized as absolute and percentage frequencies, whereas numerical variables were summarized using the mean, median, standard deviation, minimum, and maximum values. Associations between qualitative variables were assessed using Pearson's chi-square test. Associations between qualitative and quantitative variables were assessed using the Kruskal-Wallis test. A significance level of p < .05 was adopted. IBM SPSS (version 21) was used.

The qualitative stage used a descriptive and exploratory design. Participants were selected based on the quantitative analysis to deepen the investigation and understand how older adults experienced limitations in clinical-functional capacity in their daily lives. Data for this stage were collected between June and August 2023 through semi-structured interviews. The interviews were conducted individually and in person by the researcher responsible for the study, audio-recorded, and transcribed verbatim after participants provided written informed consent by signing the consent form. Theoretical data saturation, defined as the point at which no new elements emerged from the data, was used as the criterion for ending the interviews and determining the number of participants.

Qualitative data were analyzed according to the principles of thematic analysis¹⁹, comprising the following stages: (1) exploratory phase; (2) interpretive stage; (3) final analysis; and (4) reporting. Statements were identified using codes composed of the letter “E” (for “interviewee”), followed by an ordinal number (E1 to E22) that did not correspond to the interview order, as well as the letters “M” (male) or “F” (female) and the participant's age, to preserve anonymity. Data obtained in the quantitative and qualitative stages were integrated through connection, as recommended for mixed-methods studies¹⁴ and in accordance with the Pillar Integration Process for presenting a joint display²⁰. In the joint display, excerpts were edited to improve grammatical readability and facilitate reader comprehension without changing their meaning.

All ethical principles for research involving human subjects were respected, in accordance with Resolution No. 466/2012 of the National Health Council. This study is part of a broader master's thesis research project, whose parent study was approved by the Institutional Research Ethics Committee.

RESULTS

The sociodemographic profile of the older adults participating in the study was characterized by a mean age of 71.3 years (±7.475) and a predominance of the 60-74 age group; women, 231 (64.9%), outnumbered men; there was a prevalence of older adults with low educational attainment, 317 (89.0%); 197 (55.3%) were married or in a stable union; and 189 (53.0%) had a reduced monthly income.

According to the IVCF-20 assessment, low risk for clinical-functional vulnerability prevailed, 193 (54.2%). However, significant numbers, 97 (27.2%) and 66 (18.6%), presented moderate and high risk for clinical-functional vulnerability, respectively.

Being female, having low educational attainment, and having experienced health changes during the COVID-19 pandemic (such as depression, anxiety, arterial hypertension, diabetes mellitus, osteoarticular diseases, and digestive and cardiac diseases) were statistically significant factors associated with moderate to high risk for clinical-functional vulnerability. In addition, advanced age, worse self-perceived health, lower autonomy in basic and instrumental activities of daily living, multiple comorbidities, cognitive decline, and changes in mood, mobility, and communication showed statistical significance for moderate to high risk of clinical-functional vulnerability. Data on participant characterization and the factors associated with clinical-functional vulnerability are presented in Table 1.

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Table 1 -
Characterization of participants and analysis of factors associated with clinical-functional vulnerability in older adults in Primary Health Care. Rural municipality, Rio Grande do Sul, Brazil, 2023 (n = 356).

In the analysis of the sociodemographic profile and health conditions of the qualitative stage participants, the minimum age was 60 years and the maximum was 88 years, with a mean of 74.2 years. In addition, 16 (72.7%) were female and six (27.3%) were male. There was a prevalence of older adults with no schooling or who had studied only up to elementary education, 21 (95.4%) people, and one (5.6%) participant had attended high school. Regarding marital status, 12 (54.5%) were married, eight (36.4%) were widowed or divorced, and two (9.1%) were single. Regarding religion, 14 (63.6%) were Catholic, and eight (36.4%) were Evangelical. Monthly income ranged from up to one minimum wage for 16 (72.7%), to more than one minimum wage per month for six (27.3%). All participants in this stage had some chronic disease, among which arterial hypertension, diabetes mellitus, depression, and cancer stood out, and most, 12 (54.6%), used polypharmacy.

Thematic analysis of the qualitative data yielded five categories: (1) Sociodemographic characteristics associated with clinical-functional vulnerability; (2) A difficult cycle to break: the interrelationship between adverse clinical conditions and clinical-functional vulnerability; (3) Impacts of the COVID-19 pandemic on the physical and mental health of older adults; (4) Repercussions of physical limitations on the autonomy of older adults; and (5) Interfaces between cognitive and sensory decline and clinical-functional vulnerability.

In the joint display, presented in Chart 1, the integrated results are shown, highlighting the categories and excerpts from the thematic analysis, as well as a summary of the statistical associations. Metainferences are then proposed based on the inferences obtained from each individual approach. These findings made it possible to demonstrate how older adults experienced situations of clinical-functional vulnerability in their daily lives, and the repercussions for their well-being and for the maintenance of their autonomy and independence.

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Chart 1 -
Joint display of the integration of quantitative and qualitative results and metainferences regarding clinical-functional vulnerability in older adults in Primary Health Care. Rural municipality, Rio Grande do Sul, Brazil, 2023.

DISCUSSION

This study analyzed self-perceived health conditions and the aspects associated with clinical-functional vulnerability in older adults enrolled in PHC. Among its strengths, the mixed-methods design and the use of valid and reliable data collection instruments stand out, which allowed for a comprehensive and in-depth analysis of clinical-functional vulnerability among study participants.

Notably, most older adults had low risk of clinical-functional vulnerability, findings that converge with those of other studies³^,⁵. However, they diverge from results found in the North¹¹ and Southeast²¹ regions of Brazil, where most older individuals presented moderate to high risk of clinical-functional vulnerability. Nonetheless, it is important to point out that about 45% of the participants in the present study were associated with moderate to high risk, which reinforces the relevance of the topic and the regional differences.

In addition, the results demonstrated that sociodemographic characteristics (such as advanced age, female gender, and low educational attainment) are intrinsically associated with moderate to high risk of clinical-functional vulnerability in older adults. In daily life, older adults perceive vulnerability through fatigue (even with minimal effort), sarcopenia, and frailty, associating them mainly with advanced age.

Corroborating this result, a study²² found that the risk of functional decline increases with advancing age. Women, who frequently have greater longevity, are also more exposed to risk factors, functional impairment, and a higher frequency of polypharmacy²¹.

Low educational attainment had a high prevalence, that is, 89.0% among older adults. Of these, most reported having no schooling or having completed only the early years of elementary education. As a result of their limited educational level, participants experienced limitations in performing activities independently and autonomously, such as organizing and managing continuous-use medications and handling their finances, highlighting their vulnerabilities and their dependence on family assistance. Older adults with low literacy levels, whose competence to read and understand written texts and concepts is not guaranteed, present worse cognitive skills, which are reflected in worse self-care and well-being²³.

The interrelationship between adverse clinical conditions and the functionality of older adults was also evident, forming a cycle of vulnerability that is difficult to break. Worse self-perceived health, the presence of comorbidities (especially arterial hypertension, diabetes mellitus, and depression), and polypharmacy use were significant factors for moderate to high risk of clinical-functional vulnerability. Accordingly, polypharmacy use (31.5%) was relatively high compared with the findings of other studies⁵^,¹¹, in which the prevalence was 21.40% and 13.91%, respectively. That study¹¹ also indicates that, in the group of people with polypharmacy, 57.97% had at least one potentially inappropriate medication in their medical record, of whom 62.5% were vulnerable older adults.

Considering this, in the present investigation, the statements showed that the use of controlled medications can lead to side effects, such as dizziness and falls, worsening frailty in older adults. The incidence of falls and femoral fractures in older individuals is associated with the use of sedative medications, especially benzodiazepines²⁴.

Furthermore, the burden of comorbidities, mobility challenges, difficulty accessing health services, and barriers to treatment create a scenario of limitations that compromise both autonomy and well-being, contributing to a state of progressive dependence. Older adults living in rural areas of the country are more susceptible to vulnerabilities, owing to lower access to medical and dental appointments and to health services, compared with individuals living in urban areas²⁵. This indicates the need for integrated strategies for health promotion and qualified geriatric care.

During the COVID-19 pandemic, in particular, the self-perceived health changes reported by older adults also represented significant negative impacts, associated with an increased risk of clinical-functional vulnerability. Similar results were found in another study²⁶ conducted within PHC, in which 53% of the older participants transitioned to a state of pre-frailty during the pandemic.

Social isolation, necessary for containing the virus, resulted in a loss of social engagement, including the interruption of community and religious activities, reinforced feelings of sadness and hopelessness, and, in some cases, led to the need for pharmacological interventions to manage psychological distress. In addition, limited social interaction prevented the emotional and affective support that is fundamental to the well-being of older adults, worsening the pandemic's impact on their mental health. During the COVID-19 pandemic, the daily lives of older adults were permeated by changes in habits and adaptation to imposed changes, marked by anxiety, fears, the loss of friends and family members, distressing news, and changes in sociability²⁷. These findings highlight the importance of strategies aimed at promoting the emotional health of older adults, especially in situations of health crisis.

Similarly, the decreased capacity to perform basic and instrumental activities of daily living, associated with changes in mobility, showed a strong relationship with moderate to high risk of clinical-functional vulnerability. In Colombia, a study²⁸ also identified functional limitations in older adults in performing activities of daily living, associated with age, cognitive dysfunction, and fall risk.

The results indicate that pain, muscle weakness, urinary incontinence, and fall episodes generate limitations that increase dependence in performing daily tasks, reinforce social isolation, and worsen functional and emotional decline. Difficulty with locomotion and loss of fine motor skills compromise safety and quality of life, generating a progressive cycle of frailty. Falls are a common problem among older adults, associated with urinary loss, dependence for basic activities of daily living, and polypharmacy²⁹.

The interaction between cognitive, emotional, and sensory decline was also significant for clinical-functional vulnerability in older adults, affecting adaptive capacity and the risk of health deterioration. Consequently, cognitive impairment, low educational level, and a history of hospitalization in the last six months are associated with a higher incidence of hospitalization and death³⁰. Memory loss compromises autonomy and can hinder the performance of daily tasks, while mood changes, such as sadness and hopelessness, reduce engagement in enjoyable and social activities, favoring isolation.

In addition, visual and hearing difficulties limit mobility and communication, make older adults feel more insecure, and restrict their active participation in the community. The statements show that these limitations contribute to fear, grief, and loneliness, creating a cycle of physical and emotional frailty. Restrictions related to hearing loss, worsened by emotional impairment, represent a challenge in the lives of older persons, making them even more susceptible to vulnerabilities³¹. Visual and hearing changes are also frequently associated with an increased likelihood of dementia and cognitive complaints¹⁰. It is therefore essential to screen for cognitive and sensory decline and intervene early, as the ability to see and hear allows older adults to maintain functionality, autonomy, and independence¹⁰.

Overall, this study's analysis highlights the importance of PHC in the early identification of clinical-functional vulnerability in older adults, through careful approaches and the use of instruments such as the IVCF-20, as well as the need for multidisciplinary interventions, including strategies for muscle strengthening, environmental adaptation, and social support, in addition to the early screening of cognitive, sensory, and emotional decline. Nursing can play a central role in this process by coordinating care, promoting autonomy, and strengthening health education. Despite the study's methodological robustness, the results should be interpreted within the specific context of the research, underscoring the importance of complementary studies in different settings.

CONCLUSION

In this study, clinical-functional vulnerability in older adults was significantly associated with advanced age, female gender, low educational attainment, poorer self-perceived health, experiencing changes during the COVID-19 pandemic, the presence of multiple comorbidities (especially arterial hypertension, diabetes mellitus, and depression), polypharmacy, cognitive decline, mood changes, limitations in mobility and communication, and difficulties performing basic and instrumental activities of daily living. These findings demonstrate that multiple factors contribute to increased frailty in this population.

These factors did not occur in isolation but were interconnected within a complex cycle of vulnerability characterized by physical, emotional, cognitive, and social limitations. The integration of the quantitative and qualitative findings showed that vulnerability is experienced in daily life through fatigue with minimal exertion, insecurity resulting from loss of autonomy, feelings of sadness and social isolation, and difficulties with health self-management and family relationships. The mixed-methods design therefore provided a more comprehensive understanding of the phenomenon by capturing both the statistical magnitude and the lived experience of clinical-functional vulnerability, thereby supporting multidisciplinary, integrated interventions to promote healthier, more autonomous, and more dignified aging.

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» https://doi.org/10.1590/1980-265X-TCE-2020-0603
14. Creswell, JW. Projeto de pesquisa: métodos qualitativo, quantitativo e misto. 5th ed. Porto Alegre: Penso; 2021.
15. Von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP; STROBE Initiative. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: Guidelines for reporting observational studies. J Clin Epidemiol [Internet]. 2008 [cited 2025 Mar 20];61(4):344-9. Available from: https://doi.org/10.1016/j.jclinepi.2007.11.008
» https://doi.org/10.1016/j.jclinepi.2007.11.008
16. Souza VR, Marziale MH, Silva GT, Nascimento PL. Translation and validation into Brazilian Portuguese and assessment of the COREQ checklist. Acta Paul Enferm [Internet]. 2021 [cited 2025 Mar 20];34:eAPE02631. Available from: https://doi.org/10.37689/actaape/2021AO02631
» https://doi.org/10.37689/actaape/2021AO02631
17. Moraes EN de, Carmo JA do, Moraes FL de, Azevedo RS, Machado CJ, Montilla DER. Clinical-Functional Vulnerability Index-20 (IVCF-20): Rapid recognition of frail older adults. Rev Saúde Pública [Internet]. 2016 [cited 2025 Oct 2];50:81. Available from: https://doi.org/10.1590/S1518-8787.2016050006963
» https://doi.org/10.1590/S1518-8787.2016050006963
18. Moraes EN, Carmo 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 [Internet]. 2021 [cited 2025 Mar 20];22(1):31-5. Available from: https://doi.org/10.23925/1984-4840.2020v22i1a7
» https://doi.org/10.23925/1984-4840.2020v22i1a7
19. Minayo MCS. O Desafio do Conhecimento: pesquisa qualitativa em saúde. 13th ed. São Paulo: Hucitec; Rio de Janeiro: Abrasco; 2013.
20. Johnson RE, Grove AL, Clarke A. Pillar Integration Process: A Joint Display Technique to Integrate Data in Mixed Methods Research. J Mix Methods Res [Internet]. 2017 [cited 2025 Mar 20];13(3):301-20. Available from: https://doi.org/10.1177/1558689817743108
» https://doi.org/10.1177/1558689817743108
21. Jesus ECP, Pereira VG, Pereira ZAS, Marques MS, Silva CV, Siqueira LG, et al. Morbidity and factors associated with frailty in post-COVID-19 elderly patients attended at a reference center. Rev Bras Enferm [Internet]. 2024 [cited 2025 Mar 20];77(Suppl 1):e20230454. Available from: https://doi.org/10.1590/0034-7167-2023-0454
» https://doi.org/10.1590/0034-7167-2023-0454
22. Martins FG, Santiago LM. Clinical-functional vulnerability index in older people of a family health strategy team in the central zone of Rio de Janeiro. Arch Gerontol Geriatr Plus [Internet]. 2024 [cited 2025 Mar 20];1(4):e100057. Available from: https://doi.org/10.1016/j.aggp.2024.100057
» https://doi.org/10.1016/j.aggp.2024.100057
23. Aragão BM, Escarce AG, Chamouton CS, Lemos SMA. Association between older people's health literacy and sociodemographic aspects, functioning, happiness, and perception of the COVID-19 pandemic: a preliminary study. Codas [Internet]. 2025 [cited 2025 Mar 20];37(2):e20240082. Available from: https://doi.org/10.1590/2317-1782/e20240082pt
» https://doi.org/10.1590/2317-1782/e20240082pt
24. Carmo Júnior NM, Reis EA, Loyola Filho AI, Valle EA, Azevedo DC, Nascimento MMG. Profile of sedative use and occurrence of falls and hip fractures femur among older adults in a geriatric outpatient clinic. Geriatr Gerontol Aging [Internet]. 2023 [cited 2025 Mar 20];17:e0230012. Available from: https://doi.org/10.53886/gga.e0230012
» https://doi.org/10.53886/gga.e0230012
25. Alves GSB, Parente RCP, Herkrath FJ. Health services utilization by older adults in rural and urban areas of Brazil. Rev Bras Geriatr Gerontol [Internet]. 2024 [cited 2025 Mar 20];27:e230121. Available from: https://doi.org/10.1590/1981-22562024027.230121.pt
» https://doi.org/10.1590/1981-22562024027.230121.pt
26. Lenardt MH, Leta PRG, Cechinel C, Rodrigues JAM, Betiolli SE, Binotto MA. Effects of isolation and social distancing on the fragility of older people and the physical activities they perform. Aquichan [Internet]. 2024 [cited 2025 Mar 20];24(1):e2417. Available from: https://doi.org/10.5294/aqui.2024.24.1.7
» https://doi.org/10.5294/aqui.2024.24.1.7
27. Luzardo AR, Souza Silva JB de S, Bitencourt JV de OV, Maestri E, Madureira VSF, Biffi P. Percepções de idosos sobre o enfrentamento da covid-19. Cogit Enferm [Internet]. 2021 [cited 2025 Mar 20];26:e78852. Available from: https://doi.org/10.5380/ce.v26i0.78852
» https://doi.org/10.5380/ce.v26i0.78852
28. Baracaldo HA, Cadena-Sanabria MO, Serrano-Gómez S. How our population is aging. Factors associated with the functional capacity of older adults in Bucaramanga-Colombia: The ARENA Study. MedUNAB [Internet]. 2023 [cited 2025 Mar 20];26(3):464-73. Available from: https://doi.org/10.29375/01237047.4695
» https://doi.org/10.29375/01237047.4695
29. Pereira NF, Freire Júnior RC, Fernandes TG. Fatores associados a quedas e medo de cair em pessoas idosas: um estudo transversal. Estud Interdiscipl Envelhec [Internet]. 2025 [cited 2025 Mar 20];30:1-15. Available form: Available form: https://doi.org/10.22456/2316-2171.140154
» https://doi.org/10.22456/2316-2171.140154
30. Barros RS, Teixeira GTM, Pinto JM, Sampaio RX, Mendes FAS, Garcia PA. Factors predicting hospital admission and death in older adults with cognitive impairment: a longitudinal study. Texto Contexto Enferm [Internet]. 2024 [cited 2025 Mar 20];33:e20230149. Available from: https://doi.org/10.1590/1980-265X-TCE-2023-0149pt
» https://doi.org/10.1590/1980-265X-TCE-2023-0149pt
31. Campos RDDS, Pott H, Zazzetta MS, Orlandi FS, Pavarini SCI, Santos-Orlandi AAD, Jesus ITM, Say KG, Martins Gratão AC, Costa-Guarisco LP. Can hearing handicap be linked to frailty? A cross-sectional study. Codas [Internet]. 2025 [cited 2025 Mar 20];37(2):e20240107. Available from: https://doi.org/10.1590/2317-1782/e20240107en
» https://doi.org/10.1590/2317-1782/e20240107en

NOTES

ORIGIN OF THE ARTICLE
Extracted from the master's thesis - “Vulnerabilities in older adults and repercussions of the COVID-19 pandemic: a mixed-methods study,” submitted to the Graduate Program in Health and Rurality of the Universidade Federal de Santa Maria/Campus Palmeira das Missões/RS, in 2023.
FUNDING INFORMATION
Fundo de Incentivo à Pesquisa (Research Incentive Fund - FIPE) - Undergraduate Research Scholarship, in accordance with UFSM Resolution 01/2013 and CNPq Resolutions RN 017/2006 (and its annexes) and RN 023/2008. Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (Coordination for the Improvement of Higher Education Personnel - CAPES).
APPROVAL OF ETHICS COMMITTEE IN RESEARCH
Approved by the Ethics Committee in Research of the Universidade Federal de Santa Maria, opinion No. 5.639.338/2022, Certificate of Presentation for Ethical Appraisal 61689722.3.0000.5346.
TRANSLATED BY
SciTrad Brasil.
DATA AVAILABILITY
The data supporting the findings of this study are not publicly available due to ethical concerns and participant confidentiality. Additional information may be provided by the corresponding author upon justified request and ethical review.

Edited by

EDITORS
Associated Editors: Leticia de Lima Trindade.

Editor-in-chief: Gisele Cristina Manfrini.

Data availability

The data supporting the findings of this study are not publicly available due to ethical concerns and participant confidentiality. Additional information may be provided by the corresponding author upon justified request and ethical review.

Publication Dates

Publication in this collection
21 Aug 2026
Date of issue
2026

History

Received
10 Apr 2025
Accepted
10 Nov 2025

This is an open-access article distributed under the terms of the Creative Commons Attribution License

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» https://www.paho.org/pt/decada-do-envelhecimento-saudavel-nas-americas-2021-2030#:~:text=A%20popula%C3%A7%C3%A3o%20mundial%20est%C3%A1%20envelhecendo,at%C3%A9%20o%20final%20do%20s%C3%A9culo

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[9] 9. Organização das Nações Unidas - Brasil. Sobre o nosso trabalho para alcançar os Objetivos de Desenvolvimento Sustentável no Brasil [Internet]. 2025. [cited 2025 Mar 20]. Available from: https://brasil.un.org/pt-br/sdgs
» https://brasil.un.org/pt-br/sdgs

[10] 10. Rocha G, Muraro CC, Morais KB, Borba LO, Lopes MGD, Fidalski SZK. Comprometimento visual e auditivo associados à função cognitiva na população idosa: estudo transversal no Paraná, Brasil. Estud Interdiscipl Envelhec [Internet]. 2024 [cited 2025 Mar 20];29(Suppl):1-6. Available from: https://doi.org/10.22456/2316-2171.142520
» https://doi.org/10.22456/2316-2171.142520

[11] 11. Andrade RC, Santos MM, Ribeiro EE, Santos Júnior JDO, Campos HLM, Leon EB. Polypharmacy, potentially inappropriate medications, and the vulnerability of older adults. Rev Bras Geriatr Gerontol [Internet]. 2024 [cited 2025 Mar 20];27:e230191. Available from: https://doi.org/10.1590/1981-22562024027.230191.pt
» https://doi.org/10.1590/1981-22562024027.230191.pt

[12] 12. Oliveira JLC, Magalhães AMM, Mastuda LM, Santos JLG, Souta RQ, Riboldi CO, Ross R. Mixed methods appraisal tool: strengthening the methodological rigor of mixed methods research studies in nursing. Texto Contexto Enferm [Internet]. 2021 [cited 2025 Mar 20];30:20200603. Available from: https://doi.org/10.1590/1980-265X-TCE-2020-0603
» https://doi.org/10.1590/1980-265X-TCE-2020-0603

[13] 13. Oliveira JLC, Magalhães AMM, Mastuda LM, Santos JLG, Souta RQ, Riboldi CO, Ross R. Mixed methods appraisal tool: strengthening the methodological rigor of mixed methods research studies in nursing. Texto Contexto Enferm [Internet]. 2021 [cited 2025 Mar 20];30:20200603. Available from: https://doi.org/10.1590/1980-265X-TCE-2020-0603
» https://doi.org/10.1590/1980-265X-TCE-2020-0603

[14] 14. Creswell, JW. Projeto de pesquisa: métodos qualitativo, quantitativo e misto. 5th ed. Porto Alegre: Penso; 2021.

[15] 15. Von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP; STROBE Initiative. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: Guidelines for reporting observational studies. J Clin Epidemiol [Internet]. 2008 [cited 2025 Mar 20];61(4):344-9. Available from: https://doi.org/10.1016/j.jclinepi.2007.11.008
» https://doi.org/10.1016/j.jclinepi.2007.11.008

[16] 16. Souza VR, Marziale MH, Silva GT, Nascimento PL. Translation and validation into Brazilian Portuguese and assessment of the COREQ checklist. Acta Paul Enferm [Internet]. 2021 [cited 2025 Mar 20];34:eAPE02631. Available from: https://doi.org/10.37689/actaape/2021AO02631
» https://doi.org/10.37689/actaape/2021AO02631

[17] 17. Moraes EN de, Carmo JA do, Moraes FL de, Azevedo RS, Machado CJ, Montilla DER. Clinical-Functional Vulnerability Index-20 (IVCF-20): Rapid recognition of frail older adults. Rev Saúde Pública [Internet]. 2016 [cited 2025 Oct 2];50:81. Available from: https://doi.org/10.1590/S1518-8787.2016050006963
» https://doi.org/10.1590/S1518-8787.2016050006963

[18] 18. Moraes EN, Carmo 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 [Internet]. 2021 [cited 2025 Mar 20];22(1):31-5. Available from: https://doi.org/10.23925/1984-4840.2020v22i1a7
» https://doi.org/10.23925/1984-4840.2020v22i1a7

[19] 19. Minayo MCS. O Desafio do Conhecimento: pesquisa qualitativa em saúde. 13th ed. São Paulo: Hucitec; Rio de Janeiro: Abrasco; 2013.

[20] 20. Johnson RE, Grove AL, Clarke A. Pillar Integration Process: A Joint Display Technique to Integrate Data in Mixed Methods Research. J Mix Methods Res [Internet]. 2017 [cited 2025 Mar 20];13(3):301-20. Available from: https://doi.org/10.1177/1558689817743108
» https://doi.org/10.1177/1558689817743108

[21] 21. Jesus ECP, Pereira VG, Pereira ZAS, Marques MS, Silva CV, Siqueira LG, et al. Morbidity and factors associated with frailty in post-COVID-19 elderly patients attended at a reference center. Rev Bras Enferm [Internet]. 2024 [cited 2025 Mar 20];77(Suppl 1):e20230454. Available from: https://doi.org/10.1590/0034-7167-2023-0454
» https://doi.org/10.1590/0034-7167-2023-0454

[22] 22. Martins FG, Santiago LM. Clinical-functional vulnerability index in older people of a family health strategy team in the central zone of Rio de Janeiro. Arch Gerontol Geriatr Plus [Internet]. 2024 [cited 2025 Mar 20];1(4):e100057. Available from: https://doi.org/10.1016/j.aggp.2024.100057
» https://doi.org/10.1016/j.aggp.2024.100057

[23] 23. Aragão BM, Escarce AG, Chamouton CS, Lemos SMA. Association between older people's health literacy and sociodemographic aspects, functioning, happiness, and perception of the COVID-19 pandemic: a preliminary study. Codas [Internet]. 2025 [cited 2025 Mar 20];37(2):e20240082. Available from: https://doi.org/10.1590/2317-1782/e20240082pt
» https://doi.org/10.1590/2317-1782/e20240082pt

[24] 24. Carmo Júnior NM, Reis EA, Loyola Filho AI, Valle EA, Azevedo DC, Nascimento MMG. Profile of sedative use and occurrence of falls and hip fractures femur among older adults in a geriatric outpatient clinic. Geriatr Gerontol Aging [Internet]. 2023 [cited 2025 Mar 20];17:e0230012. Available from: https://doi.org/10.53886/gga.e0230012
» https://doi.org/10.53886/gga.e0230012

[25] 25. Alves GSB, Parente RCP, Herkrath FJ. Health services utilization by older adults in rural and urban areas of Brazil. Rev Bras Geriatr Gerontol [Internet]. 2024 [cited 2025 Mar 20];27:e230121. Available from: https://doi.org/10.1590/1981-22562024027.230121.pt
» https://doi.org/10.1590/1981-22562024027.230121.pt

[26] 26. Lenardt MH, Leta PRG, Cechinel C, Rodrigues JAM, Betiolli SE, Binotto MA. Effects of isolation and social distancing on the fragility of older people and the physical activities they perform. Aquichan [Internet]. 2024 [cited 2025 Mar 20];24(1):e2417. Available from: https://doi.org/10.5294/aqui.2024.24.1.7
» https://doi.org/10.5294/aqui.2024.24.1.7

[27] 27. Luzardo AR, Souza Silva JB de S, Bitencourt JV de OV, Maestri E, Madureira VSF, Biffi P. Percepções de idosos sobre o enfrentamento da covid-19. Cogit Enferm [Internet]. 2021 [cited 2025 Mar 20];26:e78852. Available from: https://doi.org/10.5380/ce.v26i0.78852
» https://doi.org/10.5380/ce.v26i0.78852

[28] 28. Baracaldo HA, Cadena-Sanabria MO, Serrano-Gómez S. How our population is aging. Factors associated with the functional capacity of older adults in Bucaramanga-Colombia: The ARENA Study. MedUNAB [Internet]. 2023 [cited 2025 Mar 20];26(3):464-73. Available from: https://doi.org/10.29375/01237047.4695
» https://doi.org/10.29375/01237047.4695

[29] 29. Pereira NF, Freire Júnior RC, Fernandes TG. Fatores associados a quedas e medo de cair em pessoas idosas: um estudo transversal. Estud Interdiscipl Envelhec [Internet]. 2025 [cited 2025 Mar 20];30:1-15. Available form: Available form: https://doi.org/10.22456/2316-2171.140154
» https://doi.org/10.22456/2316-2171.140154

[30] 30. Barros RS, Teixeira GTM, Pinto JM, Sampaio RX, Mendes FAS, Garcia PA. Factors predicting hospital admission and death in older adults with cognitive impairment: a longitudinal study. Texto Contexto Enferm [Internet]. 2024 [cited 2025 Mar 20];33:e20230149. Available from: https://doi.org/10.1590/1980-265X-TCE-2023-0149pt
» https://doi.org/10.1590/1980-265X-TCE-2023-0149pt

[31] 31. Campos RDDS, Pott H, Zazzetta MS, Orlandi FS, Pavarini SCI, Santos-Orlandi AAD, Jesus ITM, Say KG, Martins Gratão AC, Costa-Guarisco LP. Can hearing handicap be linked to frailty? A cross-sectional study. Codas [Internet]. 2025 [cited 2025 Mar 20];37(2):e20240107. Available from: https://doi.org/10.1590/2317-1782/e20240107en
» https://doi.org/10.1590/2317-1782/e20240107en

Variables	Clinical-functional vulnerability risk
	Total	Low	Moderate	High	p
	n (%)	n (%)	n (%)	n (%)	p
Age (years)
60-74	235 (66.0)	143 (60.9)	63 (26.8)	29 (12.3)
75-84	103 (28.9)	47 (45.6)	31 (30.1)	25 (24.3)
≥ 85	18 (5.1)	3 (16.7)	3 (16.7)	12 (66.6)	.000^*
Gender
Male	125 (35.1)	82 (65.6)	24 (19.2)	19 (15.2)
Female	231 (64.9)	111 (48.1)	73 (31.6)	47 (20.3)	.006^†
Educational level
No schooling or elementary education	317 (89.0)	159 (50.1)	93 (29.3)	65 (20.6)	.000^†
High school/higher education	39 (11.0)	34 (87.2)	4 (10.3)	1 (2.5)
Marital status
Single/widowed/divorced	159 (44.7)	77 (48.4)	49 (30.8)	33 (20.8)	.053^†
Married/stable union	197 (55.3)	116 (58.8)	48 (24.4)	33 (16.8)
Monthly income
≤ 1 MW^‡	189 (53.1)	92 (48.7)	57 (30.1)	40 (21.2)	.218^†
> 1 MW	167 (46.9)	101 (60.5)	40 (24.0)	26 (15.5)
Self-perceived health
Excellent/very good/good	192 (54.0)	125 (65.1)	49 (25.5)	18 (9.4)
Fair/poor	164 (46.0)	68 (41.4)	48 (29.3)	48 (29.3)	.000^†
Self-perceived change in health during the COVID-19 pandemic
Yes	71 (20.0)	27 (38.0)	26 (36.6)	18 (25.4)	.009^†
No	285 (80.0)	166 (58.2)	71 (25.0)	48 (16.8)
Multiple comorbidities
Presence of chronic disease	269 (75.6)	127 (47.2)	83 (30.8)	59 (21.9)	.000^†
Diabetes mellitus	77 (21.6)	32 (41.5)	23 (30.0)	22 (28.5)	.014^†
Arterial hypertension	235 (66.0)	109 (46.4)	70 (29.8)	56 (23.8)	.000^†
Depression	40 (11.2)	12 (30.0)	15 (37.5)	13 (32.5)	.003^†
Polypharmacy	112 (31.5)	38 (34.0)	38 (34.0)	36 (32.0)	.000^†
Basic and instrumental activities of daily living
Stopped shopping	64 (18.0)	6 (9.4)	15 (23.4)	43 (67.2)	.000^†
Stopped managing their own money, expenses, or paying bills	41 (11.5)	3 (7.3)	11 (26.8)	27 (65.9)	.000^†
Stopped performing small household tasks	61 (17.1)	1 (1.6)	21 (34.4)	39 (63.4)	.000^†
Stopped bathing independently	19 (5.3)	0 (0.0)	4 (21.1)	15 (78.9)	.000^†
Cognition
Memory changes	152 (42.7)	41 (27.0)	61 (40.1)	50 (32.9)	.000^†
Mood
Discouragement, sadness, or hopelessness	96 (27.0)	17 (17.7)	39 (40.6)	40 (41.7)	.000^†
Loss of interest or pleasure in previously enjoyable activities	57 (16.0)	5 (8.8)	17 (29.8)	35 (61.4)	.000^†
Mobility
Inability to raise the arms above shoulder level	50 (14.0)	11 (22.0)	16 (32.0)	23 (46.0)	.000^†
Inability to handle or hold small objects	48 (13.4)	13 (27.1)	13 (27.1)	22 (45.8)	.000^†
Decreased aerobic and/or muscular capacity	65 (18.2)	11 (17.0)	27 (41.5)	27 (41.5)	.000^†
Difficulty walking	83 (23.3)	8 (9.6)	23 (27.7)	52 (62.7)	.000^†
≥ 2 falls in the last year	71 (20.0)	12 (16.9)	26 (36.6)	33 (46.5)	.000^†
Sphincter incontinence	50 (14.0)	2 (4.0)	19 (38.0)	29 (58.0)	.000^†
Communication
Visual difficulty	128 (36.0)	43 (33.6)	37 (28.9)	48 (37.5)	.000^†
Hearing difficulty	59 (16.5)	10 (16.9)	23 (39.0)	26 (44.1)	.000^†

Statistical analysis	Excerpts from the thematic analysis	Metainferences
Category 1: Sociodemographic characteristics associated with clinical-functional vulnerability
Advanced age (p = .000^), female gender* (p = .006^†), and low educational attainment (p = .000^†) were statistically significant factors for moderate to high risk of clinical-functional vulnerability.	I am quite old now. It seems that whenever I am doing some housework, I get very tired (E3-F87). I have the willingness, but I no longer have the strength. I feel like I am getting weaker as I get older (E10-M75). I ask my daughter-in-law for help. She is the one who organizes all my medication. She is everything to me. Since the pandemic, I no longer go to the bank; only she goes to collect the money and then gives it to me (E20-F79). My mother never enrolled me in school. Never! She only taught me to work. She hands me some “papers” like this and I say: “But look, I do not know how to read.” [...] “Oh! You keep the money [a family member], because I do not know about money” (E2-F71).	The integrated analysis of the results indicates that advanced age, female gender, and low educational attainment are determining factors for clinical-functional vulnerability. The statements reinforce this association by expressing physical and functional limitations related to aging, such as decreased muscle strength and fatigue when performing daily activities. In addition, low educational attainment deepens these limitations, affecting self-management capacity and increasing the need for social, and especially family, support.
Category 2: A difficult cycle to break: the interrelationship between adverse clinical conditions and clinical-functional vulnerability
Worse self-perceived health (p = .000^†), presence of comorbidities (p = .000^†), especially arterial hypertension (p = .000^†), diabetes mellitus (p = .014^†) and depression (p = .003^†), and use of polypharmacy (p = .000^†) were statistically significant factors for the occurrence of moderate to high risk of clinical-functional vulnerability.	My goodness! About six types of medication, I think. I could not sleep with the medications I was taking. So I went to the doctor and he prescribed a “black label” medication, a controlled-use drug. I could not go out on the street, “I looked drunk,” with dizziness. One morning, when I got up, I ended up falling in my room (E12-F66). I still have only two teeth. Now, one has started to hurt and I will have to have it pulled. I have not had it pulled only because of my high blood pressure. One day I went to the health center, it was very high, and it was not possible to pull the tooth. But it is bothering me. It feels like a thorn inside my mouth (E1-F62). I cannot walk. For me, going to the health center is a sad thing. I have a heart problem and I run out of breath (E15-F72).	Comorbidities and their treatments intensify the barriers to the well-being of older adults, perpetuating a cycle of physical and psychological limitations and dependence. In this sense, it can be inferred that the clinical condition of older adults, when comorbidities are present, worsens self-perceived health and leads to polypharmacy. In turn, this can cause side effects that require additional medications for control. The excessive use of medications, and the use of medications contraindicated for older adults, can lead to dizziness and falls. Likewise, impaired dentition causes difficulty eating, which hinders blood pressure control, a factor that prevents tooth extraction. Furthermore, comorbidities are reflected in the worsening of the clinical condition and in physiological imbalance. As a consequence, this affects activities such as the simple act of walking, which hinders access to health services.
Category 3: Impacts of the COVID-19 pandemic on the physical and mental health of older adults
Change in health during the COVID-19 pandemic (p = .009^†) showed statistical significance for moderate to high risk of clinical-functional vulnerability.	It was a very sad experience. I only spent time with the people in my house and I could not even go to church, because activities were suspended. It was like being in a prison. I even felt signs of depression from being shut in for so long. I sought medical care and was given medication. During that period, during the pandemic, there was no movement of people in the streets. My granddaughter would sometimes joke when she saw me sweeping the sidewalk and say: “Grandma, come inside, the junk truck is going by” (E7-F63). I felt sad and discouraged. I could not talk to people, and all my relatives had that disease [COVID-19] (E20-F79). I started feeling this after I had COVID. If I go out and it is a little cold, I start shaking nonstop, it only gets better when I bundle up. Before, this did not happen. About two weeks ago, I started coughing, and the cough will not go away at all (E11-F84).	The results suggest that the COVID-19 pandemic health crisis worsened pre-existing conditions and triggered new physical and emotional frailties. The statements indicate feelings of sadness and depressive symptoms, intensified by social isolation and the loss of community engagement, as demonstrated by the inability to attend church and interact with family members. In addition, the onset or worsening of physical symptoms after the pandemic suggests possible sequelae of the infection or the impacts of a long period of inactivity and social restriction.
Category 4: Repercussions of physical limitations on the autonomy of older adults
No longer performing basic and instrumental activities of daily living (p = .000^†) and changes in mobility (p = .000^†) were statistically significant factors associated with moderate to high risk of clinical-functional vulnerability.	With this hand, yes, I can hold things. But with this one, no. Not even a glass of water. I spill everything (E14-M76). I experience urine loss. I have to use those pads. It started about seven or eight months ago (E7-F63). I cannot walk the distance from here to the corner. I cannot manage to walk without stopping. I have pain in my lower legs, it feels like I have no strength, I drag myself when I walk (E10-M75). I fell. I stepped on a rug and fell sideways. I hit my arm, it hurt, and it even swelled a little (E11-F84).	Physical limitations, such as pain, lack of strength, urinary incontinence, fall episodes, and difficulty walking, limit the ability to perform daily tasks and move independently. Therefore, mobility difficulties, combined with limited fine motor skills and balance, compromise functional autonomy, increase dependence, and promote social isolation among older adults, which further increases the risk of clinical-functional vulnerability.
Category 5: Interfaces between cognitive and sensory decline and clinical-functional vulnerability
Cognitive changes, such as memory loss (p = .000^†), mood changes, such as discouragement, sadness, hopelessness, and loss of interest in previously enjoyable activities (p = .000^†), and visual and hearing difficulties (p = .000^†) were statistically significant factors associated with moderate to high risk of clinical-functional vulnerability.	I walk, but only here in the yard. I do not go outside. Because I cannot see well, so I am afraid to go out. With this eye here, I cannot see, it looks like smoke when I look at the street (E3-F87). I feel sad when I remember my children who died (E1-F62). In this ear I can still hear well. But in this other one, I think only about 40% (E10-M75). I have had a bit of memory loss since I got sick. Sometimes I put things away and have to think about where I put them. Often I cannot remember (E16-M84).	The results reinforce the interconnection between cognitive, emotional, and sensory decline in determining clinical-functional vulnerability. The reported memory loss reinforces the statistical association found, indicating a direct impact on autonomy and on the ability to manage daily activities. In addition, feelings of sadness and hopelessness, especially those associated with significant losses, indicate impaired emotional well-being, which can intensify disinterest in previously enjoyable activities. Visual and hearing difficulties also emerge as limiting factors for mobility and social interaction, compromising older adults' communication.