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Revista de Saúde Pública

Print version ISSN 0034-8910On-line version ISSN 1518-8787

Rev. Saúde Pública vol.54  São Paulo  2020  Epub Apr 06, 2020

https://doi.org/10.11606/s1518-8787.2020054001735 

Original Article

Robust older adults in primary care: factors associated with successful aging

Luciana Colares MaiaI 
http://orcid.org/0000-0001-6359-3593

Thomaz de Figueiredo Braga ColaresII 
http://orcid.org/0000-0003-3215-447X

Edgar Nunes de MoraesIII 
http://orcid.org/0000-0002-8923-1029

Simone de Melo CostaIV 
http://orcid.org/0000-0002-0266-018X

Antônio Prates CaldeiraV 
http://orcid.org/0000-0002-9990-9083

IUniversidade Estadual de Montes Claros - Unimontes. Centro de Ciências Biológicas e da Saúde (CCBS). Departamento de Clínica Médica. Montes Claros, MG, Brasil

IIUniversidade Estadual de Montes Claros - Unimontes. Centro Mais Vida Eny Faria de Oliveira (CRASI-EFO). Montes Claros, MG, Brasil

IIIUniversidade Federal de Minas Gerais. Faculdade de Medicina. Departamento de Clínica Médica. Belo Horizonte, MG, Brasil

IVUniversidade Estadual de Montes Claros - Unimontes. Centro de Ciências Biológicas e da Saúde (CCBS). Departamento de Odontologia. Montes Claros, MG, Brasil

VUniversidade Estadual de Montes Claros - Unimontes. Centro de Ciências Biológicas e da Saúde (CCBS). Departamento de Saúde da Mulher e da Criança. Montes Claros, MG, Brasil


ABSTRACT

OBJECTIVE

To estimate the prevalence of robustness among older adults assisted in primary health care and identify factors in successful aging.

METHODS

This is a cross-sectional study conducted with older adults in Northern Minas Gerais, Brazil. Two questionnaires were used for data collection: the Brazilian Older Americans Resources and Services Multidimensional Function Assessment Questionnaire (BOMFAQ) and the Clinical-Functional Vulnerability Index IVCF-20). The adjusted prevalence ratios were obtained by robust Poisson regression. Statistical analysis was performed for older adults in general (60 to 107 years) and stratified by age: from 60 to 79 years and 80 years or more.

RESULTS

A total of 1,750 older adults aged 60 to 107 years participated; between them, 48.7% were robust. Older adults aged 60 to 79 years (n = 1,421) and 80 years or more (n = 329) had a prevalence of robustness of 55.4% and 19.3%, respectively. Some factors associated with successful aging were: positive self-perception of health, dancing habits, walking habits, absence of cognitive impairment, absence of depressive symptoms and polypathology, as well as daily life independence. After adjustment by age, the absence of polypathology and independence for activities of daily living stand out for robustness between 60 and 79 years; in those aged 80 years and over, independence for activities of daily living and dance practice presented greater strength of association.

CONCLUSION

The prevalence of robust older adults in primary care is considered satisfactory for the older population in general but decreases with age and is associated with the absence of diseases and disabilities. These results denote the need to redesign the health care system, focusing on promoting and preventing clinical-functional vulnerability.

Key words: Older Adults; Healthy Aging; Healthy Lifestyle; Protective Factors; Primary Health Care; Cross-Sectional Studies

RESUMO

OBJETIVO

Estimar a prevalência de robustez entre idosos assistidos na atenção primária à saúde e identificar fatores de envelhecimento bem-sucedido.

MÉTODOS

Trata-se de pesquisa transversal, realizada com idosos no norte de Minas Gerais, Brasil. Foram utilizados dois questionários para coleta de dados: Brazilian Older Americans Resources and Services Multidimensional Function Assessment Questionnaire (BOMFAQ) e Índice de Vulnerabilidade Clínico-Funcional (IVCF-20). As razões de prevalências ajustadas foram obtidas por análise de regressão de Poisson múltipla com variância robusta. A análise estatística foi realizada para os idosos em geral (60 a 107 anos) e estratificada por idade: de 60 a 79 anos e 80 anos ou mais.

RESULTADOS

Participaram 1.750 idosos, com idade de 60 a 107 anos, sendo 48,7% robustos. Idosos de 60 a 79 anos (n = 1.421) e 80 anos ou mais (n = 329) apresentaram prevalência de robustez de 55,4% e 19,3%, respectivamente. Associaram-se ao envelhecimento bem-sucedido: autopercepção positiva da saúde, dançar, fazer caminhada, não ter comprometimento cognitivo, ausência de sintomas depressivos e de polipatologia, além de independência para atividades de vida diária. Após ajuste por idade, destacam-se para robustez entre 60 a 79 anos a ausência de polipatologia e a independência para atividades de vida diária; naqueles com 80 anos e mais, a independência para atividades de vida diária e a prática de dança apresentaram maior força de associação.

CONCLUSÃO

A prevalência de idosos robustos na atenção primária pode ser considerada satisfatória para os idosos em geral, mas reduz com a idade e se associa com a ausência de doenças e incapacidades. Esses resultados denotam a necessidade de redesenhar o sistema de atenção à saúde, com foco na promoção e prevenção da vulnerabilidade clínico-funcional.

Palavras-Chave: Idoso; Envelhecimento Saudável; Estilo de Vida Saudável; Fatores de Proteção; Atenção Primária à Saúde; Estudos Transversais

INTRODUCTION

The 21st century is characterized by an important change in the global population pyramid, based on the significant growth of older people, both in developed and developing countries1. This demographic phenomenon brings profound epidemiological changes, which imply new challenges for health systems2. It is necessary to minimize the consequences of the aging process, seeking to keep older adults functionally independent for as long as possible1,2,5. Individual aging is not the only cause of functional decline but the main risk factor for the accumulation of chronic health conditions, which tend to decrease functionality and quality of life, besides generating more costs for health systems6.

The expression “successful aging” arose from the acknowledgment of the individual, heterogeneous and irreversible nature of the aging process7,8 and can be understood as the reduction in the functional reserve without, however, compromising the necessary function for the activities of daily living2. Healthy older adults are those capable of managing their own life and determining when, where and how their leisure activities, social life and work will occur, regardless of the presence of comorbidities, autonomously and independently4. Rowe and Kahn’s classic definition of successful aging determines objective biomedical criteria, based on the absence of diseases and disabilities, maintaining physical and cognitive capacity, and active engagement with life9.

In a broader conception, successful aging would be the vector resulting from the multidimensional interaction between physical and mental health, independence in daily life, social integration, family support and economic independence1,7. This perspective is adopted in the most recent health care guidelines for older adults of the Brazilian Ministry of Health10and the World Health Organization (WHO)1. In this expanded conception of aging, although most older adults have at least one chronic disease, not everyone is limited by it and many have normal lives, with control of their conditions and satisfaction with life2,4. Thus, well-being in old age, or health in an integral sense, derives from the balance between the dimensions of the functional capacity of the older person and their environment, without necessarily meaning the absence of problems4,11; thus it is important to recognize the vulnerability strata of the subjects10,12,13.

Brazilian scientific literature still demands further discussion on this theme. The expansion of the primary care network, through the Family Health Strategy (FHS) teams, as well as the increase of the older population, make it imperative to recognize successful aging and its associated factors for an effective promotion of health. Given this context, this study aimed to estimate the prevalence of robustness among older people assisted in primary health care and identify factors associated with successful aging.

METHODOLOGY

This is a population-based cross-sectional survey conducted in a city in Northern Minas Gerais, Brazil. Data were collected in 2017, interviewing the older adults assisted in primary health care (PHC) in the urban area. This year, the municipality had assistance coverage by FHS teams greater than 80%.

The sample size was based on the population estimate, and the formula for infinite population was used, with prevalence of the outcome equal to 50%, sample error of 3% and confidence interval of 95% (95%CI). The sampling was complex by clusters: regional health centers and FHS teams. Considering the sampling process, the number was multiplied by a correction factor for the design effect (deff) equal to 1.5 plus 10% for eventual losses.

The team of interviewers, composed of nurses and medical students, was specially trained for data collection. In addition, a pilot study was carried out for final calibration of instruments and interviewers (data not included in the final analysis). Data were collected at home and in the morning, evening or night periods, on all days of the week. Older adults not at their homes on at least three visits, on different days and times, even after previous scheduling, were considered losses.

Two surveys were used: the Brazilian version of Older Americans Resources and Services Multidimensional Function Assessment Questionnaire (BOMFAQ)4,14 and the Clinical-Functional Vulnerability Index IVCF-2012,13. BOMFAQ is a multidimensional tool, adapted and validated in Brazil4,14. The IVCF-20 was used for the screening of probability of clinical-functional vulnerability, with a score between 0 and 40 points. It identifies the frail older adults with sum greater than or equal to 15 points, pre-frail with a value of 7 to 14 and robust with a score less than or equal to 612,13. In this sense, the screening recognizes older adults with lower clinical-functional vulnerability, which are probably the most active and successfully aging. In this study, the IVCF-20 presenting low score (robust older adults) was taken as synonymous with successful aging. Thus, the IVCF-20score was dichotomized to compose the dependent variable: less than or equal to 6 for robust older adults and greater than or equal to 7 for non-robust older adults.

The independent variables were composed by the sociodemographic profile (sex, age group, education, marital status and family income in minimum wages at the time – R$ 937.00) while the determinants of successful aging were based on Rowe and Kahn’s traditional model9. This model, although criticized, still has influence and is widely used in the literature2,3,15. It encompasses the domains and variables evaluated in this study: social engagement (self-perception of health, reading habits, dance practice and loneliness), upkeep of physical and cognitive capacity (walking, sports practice, cognitive impairment measured by the Mini Examination of Mental State [MMSE] and depressive symptoms by the Short Psychiatric Evaluation Schedule [SPES]) and absence of diseases and disabilities (polypathology and functional independence evaluated through their activities of daily life [ADL]). All the information aforementioned was obtained from BOMFAQ and dichotomized. Polypathology was considered as five or more self-reported diseases. Total independence for ADL would be conducting basic and instrumental activities without compromises, investigated by BOMFAQ (bedtime, bathing, dressing, combing hair, cutting toenails, going to the bathroom in time, eating, going out driving, climbing a flight of stairs, walking near home, cleaning the house, medicating on time, shopping and preparing meals).

Data were processed by the IBM® SPSS® software version 22.0, and bivariate analyses were performed; followed by multiple analysis, by Poisson regression with robust variance for all variables associated with the event studied up to 20% (p < 0.20). The variables associated with successful aging up to the significance level of 5% (p < 0.05) were kept in the final model. The analysis was performed for all older adults in the study (60 to 107 years) and then for the strata between 60 to 79 years (young-old) and 80 years or more (long-lived older adults). Due to the cluster-based, complex sampling, weighting was used to estimate prevalence ratios and 95%CI.

The research was approved by the research ethics committee of the main institution of study, by opinion no. 1,628,652. Older adults participating in the study signed an informed consent form. The secrecy and confidentiality of the information collected was ensured.

RESULTS

The study included 1,750 older adults, of whom 844 (48.7%) were considered “robust,” 548 (31.2%) “pre-frail” and the remaining 357 (20.1%) “frail.” Regarding the sociodemographic characteristics of the group, we found that most of the participants were women (63.5%), literate (89.0%), had a partner or spouse (54.2%) and received up to two minimum wages (63.5%). Older adults between 60 to 69 years (PR = 1.15; 95%CI 1.11–1.19) and 70 to 79 years (PR = 1.09; 95%CI 1.06–1.13) showed a higher prevalence of robustness when compared with those aged 80 years and over, as shown in Table 1. The Figure presents the characterization in percentages of clinical-functional vulnerability by the IVCF-20 of the 1,750 older adults classified as “robust” and “non-robust,” stratified by age.

Table 1 Association between sociodemographic variables and successful aging (Poisson regression) for older adults enrolled in primary health care in Montes Claros, MG, Brazil, 2017. 

Sociodemographic variables N = 1,750 older adults n (%a) Robust older adult (IVCF-20 score ≤ 6) Bivariate analysis Multiple analysis



Yes No p PR (95%CI) p PR (95%CI)


n %a n %a
Sex <0.001 0.070
Female 1,111 (63.5) 477 43.2 633 56.8 1 1
Male 639 (36.5) 367 58.2 272 41.8 1.11 (1.07–1.14) 0.98 (0.95–1.00)
Age group < 0.001 < 0.001
80 years or older 329 (18.5) 63 19.3 266 80.7 1 1
70 to 79 years old 569 (32.5) 257 45.5 312 54.5 1.17 (1.13–1.21) 1.09 (1.06–1.13)
60 to 69 years old 852 (49.0) 524 61.8 327 38.2 1.31 (1.26–1.35) 1.15 (1.11–1.19)
Literate < 0.001
No 201 (11.0) 58 28.9 143 71.1 1 0.235 1
Yes 1,545 (89.0) 785 51.1 762 48.9 1.15 (1.10–1.20) 1.03 (0.99–1.06)
Marital status < 0.001
Without partner 803 (45.8) 327 41.0 476 59.0 1 0.978 1
With a partner 947 (54.2) 518 55.1 429 44.9 1.15 (1.10–1.21) 1.00 (0.97–1.03)
Household income 0.316
> 2 MW 1,053 (63.5) 300 50.5 298 49.5 1 - -
Up to 2 MW 568 (36.5) 500 47.9 553 52.1 1.02 (0.98–1.05)

IVCF-20: Clinical-Functional Vulnerability Index; PR: prevalence ratio; 95%CI: 95% confidence interval; MW: minimum wages at the time

a Percentage adjusted by the sample correction factor.

Figure Characterization of clinical-functional vulnerability by the Clinical-Functional Vulnerability Index (IVCF-20) of older adults stratified by age (60 to 107 years, 60 to 79 years and 80 years or older) assisted in primary health care in Montes Claros, MG, Brazil, 2017. 

Among the determinants of successful aging, in social engagement with life, 71.2% of the older adults had positive self-perception of life and 52.7% maintained reading habits. Regarding variables in upkeep of physical capacity and cognition, 28.5% had walking habits and 88.4% did not present cognitive impairment. Regarding the absence of diseases and disabilities, 27.7% did not present polypathology and 42.8% were totally independent for ADL. Robustness was associated to positive self-perception of health, dancing habits, absence of loneliness, walking habits, absence of cognitive impairment, absence of depressive symptoms, as well as not reporting five or more diseases (polypathology) and being independent for ADL (Table 2).

Table 2 Association between health-related variables and life habits and successful aging (Poisson regression) for older adults registered in primary health care in Montes Claros. MG. Brazil. 2017. 

Variables N = 1,750 older adults n (%a) Robust older adult (IVCF-20 score ≤ 6) 60 to 107 years old Bivariate analysis Multiple analysis



Yes No p PR (95%CI) p PR (95%CI)


n %a n %a
Social engagement

Self-perception of health < 0.001 < 0.001
Negative 511 (28.8) 105 20.7 406 79.3 1 1
Positive 1,239 (71.2) 739 60.0 499 40.0 1.48 (1.41–1.55) 1.19 (1.13–1.24)
Reading habits < 0.001 0.690
No 918 (52.7) 394 43.3 524 56.3 1 1
Yes 820 (47.3) 444 54.6 376 45.4 1.11 (1.05–1.16) 1.00 (0.97–1.05)
Dancing habits < 0.001 < 0.001
No 1,569 (90.2) 714 45.9 855 54.1 1 1
Yes 167 (9.8) 119 71.6 48 28.4 1.28 (1.19–1.38) 1.15 (1.09–1.27)
Loneliness < 0.001 0.007
Present 345 (19.8) 80 23.4 264 76.6 1 1
Absent 1,381 (80.2) 763 55.6 618 44.4 1.38 (1.31–1.41) 1.07 (1.02–1.13)

Upkeep of physical and cognitive capacity

Walking habits < 0.001 < 0.001
No 1,241 (71.5) 501 40.7 740 59.3 1 1
Yes 494 (28.5) 334 68.3 160 32.4 1.31 (1.24–1.38) 1.13 (1.08–1.18)
Sports practice 0.003 0.959
No 1,655 (95.4) 780 47.5 875 52.5 1 1
Yes 78 (4.6) 51 64.6 27 35.4 1.18 (1.06–1.32) 1.00 (0.91–1.09)
Cognitive impairment < 0.001 < 0.001 < 0,001
Present 201 (11.6) 42 21.7 159 78.3 1 1
Absent 1,545 (88.4) 801 52.2 744 47.8 1.34 (1.25–1.43) 1.18 (1.11–1.27)
Depressive symptoms < 0.001 < 0.001 < 0,001
Present 455 (25.9) 91 21.7 364 80.1 1 1
Absent 1,271 (74.1) 752 52.2 518 40.5 1.48 (1.41–1.55) 1.15 (1.10–1.21)

Absence of diseases and disabilities

Polypathology < 0.001 < 0.001
Yes 489 (27.7) 67 13.7 422 86.3 1 1
No 1,260 (72.3) 777 62.1 483 37.9 1.67 (1.56–1.69) 1.33 (1.27–1.39)
Functional independence for activities of daily living < 0.001 < 0.001 < 0,001
No 998 (57.2) 287 29.1 711 70.9 1 1
Yes 751 (42.8) 557 74.8 194 25.2 1.56 (1.50–1.63) 1.30 (1.24–1.36)

IVCF-20: Clinical-Functional Vulnerability Index; PR: prevalence ratio; 95%CI: 95% confidence interval

a Percentage adjusted by the sample correction factor.

In the group aged 60 to 79 years (n = 1,421), the prevalence of robustness was 55%, associated with the following variables: positive self-perception of health, dancing habits, absence of loneliness, walking habits, absence of cognitive impairment, absence of depressive symptoms, not reporting five or more diseases (polypathology) and being independent for ADL (Table 3). Among those aged 80 years or older (n = 329), the prevalence of robustness was 19.2%, associated with dance practice, walking, not having cognitive impairment, not reporting polypathology and total independence for ADL (Table 4).

Table 3 Association between health-related variables and life habits and successful aging (Poisson regression) for older adults between 60 and 79 years old registered in primary health care in Montes Claros. MG. Brazil. 2017 

Variables N = 1,421 older adults n (%a) Robust older adult (IVCF-20 score ≤ 6) 60 to 79 years old Bivariate analysis Multiple analysis



Yes No p PR (95%CI) p PR (95%CI)


n %a n %a
Social engagement

Self-perception of health < 0.001 < 0.001
Negative 406 (28.0) 97 23.9 309 76.1 1 1
Positive 1,015 (72.0) 684 67.6 330 32.4 1.32 (1.28–1.37) 1.14 (1.10–1.18)
Reading habits < 0.001 0.679
No 718 (51.0) 362 50.9 356 49.1 1 1
Yes 691 (49.0) 413 60.2 278 39.8 1.06 (1.02–1.10) 1.01 (0.92–1.04)
Dancing habits < 0.001 < 0.001
No 1,252 (88.9) 657 52.8 595 47.2 1 1
Yes 155 (11.1) 113 73.1 42 26.9 1.15 (1.09–1.23) 1.09 (1.03–1.14)
Loneliness < 0.001 0.011
Present 281 (19.8) 74 26.4 208 73.6 1 1
Absent 1,129 (80.2) 706 61.9 123 37.9 1.26 (1.22–1.31) 1.05 (1.01–1.09)

Upkeep of physical and cognitive capacity

Walking habits < 0.001 < 0.001
No 961 (68.3) 458 47.9 503 52.1 1 1
Yes 446 (31.7) 314 71.0 132 29.0 1.18 (1.13–1.23) 1.07 (1.03–1.11)
Sports practice < 0.018 0.846
No 1,338 (95.2) 721 54.3 617 45.7 1 1
Yes 67 (4.8) 47 69.3 20 30.7 1.11 (1.02–1.21) 1.01 (0.94–1.07)
Cognitive impairment < 0.001 0.005
Present 109 (7.8) 37 34.4 72 65.6 1 1
Absent 1,310 (92.2) 743 57.1 567 42.9 1.15 (1.08–1.22) 1.08 (1.02–1.14)
Depressive symptoms < 0.001 < 0.001
Present 357 (24.8) 83 23.1 274 76.9 1 1
Absent 1,054 (75.2) 697 66.4 356 33.6 1.32 (1.28–1.37) 1.11 (1.06–1.15)

Absence of diseases and disabilities

Polypathology < 0.001 < 0.001
Present 366 (25.5) 64 17.4 302 82.6
Absent 1,054 (74.5) 717 68.4 337 31.6 1.38 (1.35–1.43) 1.21 (1.17–1.24)
Functional independence for activities of daily living < 0.001 < 0.001
No 743 (52.5) 260 35.3 483 64.7 1 1
Yes 677 (47.5) 521 77.4 156 22.6 1.33 (1.29–1.39) 1.18 (1.14–1.22)

IVCF-20: Clinical-Functional Vulnerability Index; PR: prevalence ratio; 95%CI: 95% confidence interval

a Percentage adjusted by the sample correction factor.

Table 4 Association between health-related variables and life habits and successful aging (Poisson regression) for older adults over 80 years old registered in primary health care in Montes Claros. MG. Brazil. 2017. 

Variables N = 329 older adults n (%a) Robust older adult (IVCF-20 score ≤ 6) 80 years or older Bivariate analysis Multiple analysis



Yes No p PR (95%CI) p PR (95%CI)


n %a n %a
Social engagement

Self-perception of health < 0.001 0.284
Negative 105 (52.5) 08 8.3 97 91.7 1 1
Positive 224 (67.7) 55 24.5 169 75.5 1.10 (1.05–1.15) 1.04 (0.97–1.13)
Reading habits 0.135 0.828
No 200 (60.4) 32 16.0 168 84.0 1 1
Yes 129 (39.6) 31 24.2 98 75.8 1.04 (0.99–1.10) 0.99 (0.91–1.07)
Dancing habits 0.045 0.035
No 317 (96.4) 57 18.1 260 81.9 1 1
Yes 12 (3.6) 06 50.0 06 50.0 1.22 (1.02–1.48) 1.32 (1.02–1.71)
Loneliness 0.006 0.371
Present 63 (19.7) 06 9.8 57 90.2 1 1
Absent 252 (80.3) 57 22.7 195 77.3 1.07 (1.02–1.13) 0.97 (0.89–1.04)

Upkeep of physical and cognitive capacity

Walking habits < 0.001 0.026
No 280 (85.5) 43 15.5 237 84.5 1 1
Yes 48 (14.5) 20 41.9 28 58.2 1.17 (1.06–1.28) 1.16 (1.02–1.32)
Sports practice 0.243 -
No 317 (96.4) 59 18.7 258 81.3 1 -
Yes 11 (3.6) 04 38.2 07 61.8 1.11 (0.93–1.34) -
Cognitive impairment < 0.001 0.004
Present 92 (96.4) 59 18.7 258 81.3 1 1
Absent 11 (3.6) 04 38.2 07 61.8 1.10 (1.05–1.15) 1.11 (1.03–1.20)
Depressive symptoms < 0.001 0.557
Present 98 (30.5) 08 8.1 74.5 91.9 1 1
Absent 217 (69.5) 55 25.5 162 74.5 1.10 (1.05–1.15) 1.02 (0.95–1.01)

Absence of diseases and disabilities

Polypathology < 0.001 < 0.001
Yes 123 (37.3) 03 2.7 120 97.3 1 1
No 206 (62.7) 60 29.1 146 70.9 1.16 (1.11–1.21) 1.24 (1.16–1.33)
Functional independence for activities of daily living < 0.001 < 0.001
No 255 (77.8) 27 10.7 228 89.3 1 1
Yes 74 (22.2) 36 49.5 38 50.5 1.26 (1.16–1.36) 1.33 (1.18–1.51)

IVCF-20: Clinical-Functional Vulnerability Index; PR: prevalence ratio; 95%CI: 95% confidence interval

a Percentage adjusted by the sample correction factor.

DISCUSSION

Among the older adults assisted by FHS teams in PHC, the prevalence of robustness can be considered satisfactory when evaluated among all the older population in the study. Approximately half of the older adults were stratified with low clinical-functional vulnerability, that is, potentially active and independent. Other studies presented a lower percentage of robust older adults, such as Hank19(8.5%), McLaughlin15(10.9%), Curcio18(24.4%), Canedo2(25%) and Bosch-Farre20(23.5% or 38.9%, according to instrument used). In the age-adjusted analysis, there was a prevalence of robustness almost three times higher among those aged 80 years or older, similar to observations of a study in Rio de Janeiro2. In the three analysis groups (all the older adults, 60 to 79 years and 80 years or more), the following variables were associated with robustness: dancing and walking habits, absence of cognitive impairment, not reporting polypathology and total independence for ADL.

However, it is important to consider the fact there is no standardization of instruments to measure successful aging. Similarly, categorization for age groups is different among studies, as well as the methodologies used. Rowe and Kahn’s classic proposal9, despite the scientific debate about it, continues to significantly influence all discussions on this subject15. Studies on the field are promising, but there is no conceptual consensus or universally standardized instruments for the evaluation5,15,17,19.

The aging process is challenging and requires innovative health care models, that is, capable of identifying and monitoring the clinical and functional conditions of the older population quickly, early and continuously, particularly in the public health network1,5,10,11. Currently, the health of older adults should be based on the interaction of the individual’s functionality (autonomy and independence) with their environment1,5. Thus, reflections on the positive, multidimensional and integrated evolution that constitutes the aging process begin in the literature1,2,5,11,17,18,20.

IVCF-20, used in this study, was developed for the stratification of clinical-functional risk and can be considered an indicator of good health conditions, health capacity or overall functionality12,13. It allows, in addition to classifying older adults with high and moderate functional vulnerability, to identify those considered of low clinical and functional risk, i.e. robust. Individuals identified with IVCF-20 lower than seven points are healthier, more active and should keep up with the usual follow-up focusing on health prevention and promotion measures on primary care13. Primary care is the gateway to the healthcare network and acts as a coordinator of care, and therefore needs to integrate other points of healthcare with greater complexity, according to the clinical and functional conditions of the older population10,11.

In this investigation, through the analysis of all older adults, age was the significant sociodemographic variable in the final model. The reduction in the prevalence of robustness among those aged 80 years or older was evidenced in this study. Other studies, despite using different instruments, but similar criteria, also showed that young-old adults are healthier and more robust2,10,18,20. However, aging includes multidimensional issues7,8 with involvement of different predictors, which are influenced in the course of life1,11,16. Younger and more independent older adults, in favorable environments, have better perception of life and are more active than long-lived ones2. In this study, not complaining about loneliness was associated with robustness in the group of all older adults and in those aged 60 to 79 years. Therefore, the interaction between functional independence and favorable environment promotes satisfaction and success in active lifelong engagement1,2,21. Studies with those aged 80 years or older are scarce and with limited methodologies, lacking research2,22 on social engagement.

Successful aging can be reproduced in functional capacity through physical and mental skills, both essential in autonomy and independence of each individual in a friendly (physical and social) environment. This is indispensable for the well-being of every human being, in the broadest sense, including domains such as happiness, satisfaction and self-efficacy1,2. In this investigation, older adults with positive self-perception of life as well as those with dancing habits presented less clinical-functional vulnerability, probably because they developed successful trajectories in aging, with particular attention to the variable of “dancing habits” associated with robustness between long-lived older adults (80 years or older) and young-old adults (60 to 79 years). The literature also showed that older adults capable of managing their own life (autonomy) and performing leisure activities revealed a self-perception of optimistic life, which contributes to a healthy and active old age1,2,23.

In addition to those with successful aging, we should emphasize our results regarding the prevalence of non-robustness, which affects especially long-lived older adults. Therefore, it is also necessary to invest in the training of health professionals regarding clinical-functional stratification and care centered on the particularities of pre-frail and frail older adults. Given this context, professional qualification of public health teams could contribute to recovering and rehabilitating strategies regarding functionality of vulnerable individuals. It is also important that public administrators provide structurally healthy environments for this population.

The intersectoral perspective of healthy and active aging, in friendly environments, can provide both maintenance and restoration of physical and cognitive capacity1,11,21,27. Moreover, the WHO, since 2007, through the Global Network for Age-friendly Cities, already recommends friendly environments for this population. The guide suggests adapting structures and integration between systems to promote successful and active aging27. Currently, the document Brasil Amigo da Pessoa Idosa (Age-Friendly Brazil) reinforces this previous proposal and makes commitments to municipalities that meet the requirements determined by the initiative28. This strategy, in accordance with the new epidemiological and social scenario of the Brazilian population, can collaborate to addressing the challenges regarding aging, causing impacts in a beneficial way in clinical and functional capacity.

Another significant point related to healthy longevity was the fact that the older population with cognitive and functionally independent abilities acquire healthy behaviors throughout life2,24,26,29 and can even enjoy digital technology in health management30. Such statement reiterates the findings of this research, in which the interviewees considered robust showed a higher prevalence of walking habits, as well as absence of cognitive impairment or depressive symptoms. Therefore, it is fundamental to establish strategies that keep the older population highly functional for as long as possible. This contributes to successful aging20,31, with lower morbidity and mortality rates31.

The absence of disabilities and diseases comprises another group of determining factors for successful aging9. In this research, older adults without reports of polypathology and with total independence for all ADL had superiority in clinical-functional capacity in relation to their peers. These data were also found for age-stratified analysis. Other studies have also shown how the presence of disabilities and polypathology produces clinical and functional vulnerability in individuals, with negative impacts in health and lifespan1,2,4,10,18,31.

Our results should be considered in the light of some limitations. The cross-sectional study made it impossible to determine causality. Data were reported by the older adults in question, and memory bias should be considered. In addition, data collection instruments have limitations, although they allow individuals to stratify their health characteristics. From this perspective, the importance of distinguishing and referencing “frail” older adults for multidimensional clinical evaluation and preparation of the care plan should be considered, at the secondary level of the public care network, with their counter-reference longitudinal follow-up by the family health team. Individuals in frail conditions and robust individuals continue with the care of PHC professionals trained in the particularities of the health of older population, according to manuals and/or health care guidelines.

Despite the limitations presented, the sample design and the high number of older adults included ensures representativeness of the group studied. The IVCF-20 instrument is a screening questionnaire, which allows the clinical-functional stratification of the older population. It is validated and easy to apply, and can be used by any health professional, facilitating the initial screening and monitoring of this population by FHS.

In summary, this study highlighted an important prevalence of active and healthy (robust) older adults, that is, those with low clinical and functional vulnerability. However, adjusted analysis for long-lived older adults showed a significant reduction in this prevalence, a result that reinforces the urgency to redesign health care systems for the older population, with a special focus on the particularities of different age groups, in order to prolong lifetime with active engagement and free of physical or cognitive disabilities. Therefore, the need to qualify professionals in the care of older adults, with health promotion and prevention of clinical-functional vulnerability, is emphasized, delaying the development of diseases and their complications, in addition to training of the PHC team for health recovery actions and rehabilitation of functionality.

In this context, many challenges exist. New research on this theme is recommended to stimulate the study of the relationship between determinants of successful aging and older adults with low clinical-functional vulnerability (robustness), as well as evaluations on planning and implementation of public policies for that population quota.

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Funding

The authors thank Fundação de Amparo à Pesquisa do Estado de Minas Gerais (FAPEMIG) for financial support. CDS – APQ-02965-17 and Process No.: CDS-BIP00128-18) and the Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq).

Received: May 16, 2019; Accepted: August 7, 2019

Correspondence: Luciana Colares Maia Rua Primeiro Centenário, 101, Cândida Câmara - Montes Claros MG - CEP 39401-035. Tel: (38) 32248032 E-mail: luciana.colares.maia@gmail.com

Authors’ contributions: Study design: LCM, TFBC, ENM, SMC, APC. Data collection: LCM. Data analysis and interpretation: LCM, SMC, APC. Preparation and writing of the manuscript: LCM, TFBC, ENM, SMC, APC. Critical review of the manuscript: LCM, SMC, APC. Final approval: all authors. Public responsibility for the content of the article: LCM.

Conflict of Interest: The authors declare no conflict of interest.

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