Variables associated with frailty in a hospital population in Colombia

© 2020 Sociedade Brasileira de Geriatria e Gerontologia This is an open access article distributed under the terms of the Creative Commons license. Díaz DM, Ochoa A, Corzo MA, Sanabria MC, Figueroa CL Geriatr Gerontol Aging. 2020;14(2):114-9 115 INTRODUCTION Frailty, understood as a state of low physiological reserve and decreased capacity of responding to stressors,1 has been investigated by many community studies, and, less often, in acute care settings. Several diagnostic criteria for this condition have been proposed; among them, one of the most described is the Fried frailty phenotype.2,3 Reports on the prevalence of frailty have shown important variations worldwide.4-12 In Colombia, Gómez Montes et al.3 found a prevalence of 12.5% using Fried criteria in a sample of 1878 individuals aged > 60 years from 4 Colombian cities. Results from the SABE Bogotá study showed a prevalence of frailty of 9.4%. 13 Locally, the only study conducted at the community level reported a prevalence of 7.9%. 14 There are no studies assessing either frailty in hospitalized older adults at the national level or the clinical factors associated with this condition, the reason for which this study was conducted. METHODS A cross-sectional observational study was conducted including patients aged 65 years or older admitted to the internal medicine service of Hospital Universitario de Santander (HUS) from 2016 to 2017. Patients were selected using a concurrent convenience sampling strategy. Inclusion criteria were the following: age equal to or greater than 65 years, being admitted to the internal medicine service, having accepted to participate in the study, and length of hospital stay equal to or longer than 48 hours. Conversely, the study excluded patients with diseases that prevented them from being in the standing position, such as severe dementia and chronic immobility syndrome with deterioration of motor functions for more than 6 months. No invasive procedures were performed. It was considered a minimum risk study, according to the Resolution 8430 of 1993 (Colombia). Participants were asked to provide written informed consent. This research was approved by the Research Ethics Committee of HUS and of Universidad Industrial de Santander (CEINCI). According to HUS’s statistics for 2014, an average of 2735 patients older than 65 years were discharged from the internal medicine service; and, considering an estimated prevalence of frailty of 12% in Colombia, sample size was set at 155 patients for a 95% confidence interval (95%CI) and power of 80%. Variables The following variables were obtained: age, sex, place of origin, educational level, marital status, length of hospital stay, comorbidities. Additionally, anthropometric variables, such as calf circumference, were obtained, and scales to assess functional capacity in basic and instrumental activities of daily living (Barthel and Lawton scales respectively) were administered, as well as Mini Mental State Examination (MMSE), Mini nutritional assessment, short version (MNA), and Charlson Index. The definition of frailty was based on the Fried phenotype, considering the variables previously described in Colombia;3,14 assessment was conducted on the day of hospital discharge. The diagnosis of frailty was established in the presence of 3 or more of the following criteria: • Weight loss: this variable was assessed through the question from the MNE questionnaire that asked about self-reported unintentional weight loss within the last 3 months and was coded as: yes, no, or do not know. Participants who reported unintentional weigh loss within the last 3 months or who had a body mass index (BMI) < 21 kg/m2 were considered positive for this criterion; • Grip strength: grip strength was measured using a Jamar hydraulic hand dynamometer model 5030J1, 2012, Serial 31112055. Two attempts were made, with a 1-minute interval between them, and the best of the attempts was recorded. Values below 20 kg/f for women and 30 kg/f for men were considered as low grip strength; • Self-reported physical tiredness or fatigue: assessed using 2 questions belonging to the Center for Epidemiologic Studies Depression Scale-Revised (CESD-R). Participants were asked whether they felt that everything they did was an effort and if they were too tired to do anything in the previous week. The participants could answer rarely (0 or 1 day), some of the time (1 or 2 days), occasionally (3 or 4 days), and most of the time (5 a 7 days). Participants who answered “occasionally” or “most of the time” to some of the 2 questions were assigned with 1 point for this item; • Gait speed: The test consisted of asking participants to walk along a 6-meter distance at their usual walking speed. The time required for this task was recorded. Participants with a gait speed below 0.8 m/s were considered as having a slow speed; Hospitalary Frailty and associated variables Geriatr Gerontol Aging. 2020;14(2):114-9 116 • Physical activity: According to the Reuben’ Advanced Activities of Daily Living scale, participants were classified into four categories: frequent vigorous exercisers, frequent long walkers, frequent short walkers, and non-exercisers. Participants who reported not doing any exercise were considered as having low physical activity. Calf circumference was measured with individuals in the seating position and legs 30 cm apart from each other with an angle of 90 degrees. Statistical analysis Sociodemographic and clinical variables were expressed as frequencies, percentages, medians, means, according to the level of measurement, together with their corresponding dispersion measures. The variables that were significantly associated with the outcome (frailty) in the bivariate analysis were incorporated into the multivariate model to estimate the independent predictive value of each parameter, with statistical significance set at p < 0.05. Odds ratios (OR) and their 95% confidence intervals were calculated for each variable included in logistic regression. The area under the receiver operating characteristic (ROC) curve was used to assess the sensitivity and specificity of continuous and dichotomous variables with statistical significance, considering the Fried frailty criteria as the reference standard. Data analysis was conducted using the STATA 12 statistical package. RESULTS During the research period, 182 patients were selected as eligible. However, 13 met exclusion criteria, 5 did not complete the functional evaluation, and 9 withdrew consent. Finally, a total de 155 patients were included, of which 65.1% (n = 101) were male. The prevalence of frailty according to Fried criteria was 60.6% (n = 94), being higher among women (75.9%). Frail patients had a median age of 76 (IQR, 69 – 81) years and a median length of hospital stay of 10 (IQR, 6–15) days. As for anthropometric measures, mean BMI was 23.6 (SD 5.1) kg/m2, and mean calf circumference was 31.8 (SD 4.5) cm. With regard to biometric factors, mean grip strength was 19.4 (SD 5.9) kg/f, and mean gait speed was 0.6 (± 0.2) m/s. Assessment of physical activity level showed that 40.6% (n = 66) of patients were non-exercisers, 25.8% (n = 40) walked frequent short walkers, and only 14.8% (n = 23) were vigorous exercisers performed vigorous physical activity. Conversely, with regard to the questions from the CESD-R that assessed self-reported fatigue, 41.4% of respondents (n = 39) answered that they felt that everything they did was an effort most of the time (5 – 7 days). The demographic characteristics of the study population are shown in Table 1. Multivariate analysis The bivariate analysis between the variables that showed association with frailty found that a calf circumference lower than or equal to 31 cm, a gait speed lower than 0.8 m/s, and age above 75 years were associated with risk for frailty, with an OR equal to 4.2 [95%CI 1.74 – 10.15; p = 0.001]; 7.5 [95%CI 3.41 – 16.7; p < 0.001], and 2.8 [95%CI 1.23 – 6.48; p = 0.014] respectively, with a ROC curve of 0.82. When presence of fatigue and physical inactivity were added to these variables, the association between these variables and risk for frailty remained, and the value of the ROC curve increased to 0.92 (Table 2 and Graph 1). Conversely, the present study found that some variables tended to be protective, since cross-sectional analysis revealed Table 1 General characteristics of the study population. Variable Total n = 155 n (%) Non-frail n = 61 (39.35) n (%) Frail n = 94 (60.65) n (%) p-value Sociodemographic characteristics