Abstracts

Introduction

The increased longevity of the population causes people to think more deeply about the aging process and its effects on quality of life. A study with subjects aged 65 years or more aimed at assessing the perception of the elderly about their quality of life, pointed out that the majority considered ‘being healthy’ and ‘not having disabilities’ as the main definitions of the term.⁽¹1 . Paskulin LM. Elders’ perception of quality of life. Acta Paul Enferm. 2010; 23(1):101-7. Portuguese.⁾ Answers like ‘having energy’, ‘being happy’ and ‘proper functioning of the senses’ were also found.⁽²2 . Molzahn A, Skevington SM, Kalfoss M, Makaroff KS. The importance of facets of quality of life to older adults: an international investigation. Qual Life Res. 2010; 19:293-8.⁾ Although quality of life is defined in different ways, there is a consensus that it is a multidimensional concept that includes psychological, social, environmental and spiritual dimensions.⁽²2 . Molzahn A, Skevington SM, Kalfoss M, Makaroff KS. The importance of facets of quality of life to older adults: an international investigation. Qual Life Res. 2010; 19:293-8.⁾

One of the most widely used instruments to assess health-related quality of life is the SF-36 (Medical Outcomes Study 36-Item Short-Form Health Survey), developed from the Medical Outcomes Study (MOS), a questionnaire published in English in the year 1990 that is specific to the elderly population. In Brazil, the SF-36 was translated and validated in a study that examined the quality of life of individuals with rheumatoid arthritis.⁽³3 . Ciconelli RM, Ferraz MB, Santos WS, Meinão IM, Quaresma MR. [Brazilian-Portuguese version of the SF-36. A reliable and valid quality of life outcome measure]. Rev Bras Reumatol. 1999; 39(3):143-50. Portuguese.⁾ According to the author, it was adapted for use in the Brazilian population considering the local socioeconomic and cultural conditions.

The SF-36 is a questionnaire of easy application. Because of its reproducibility and validity, the questionnaire is an additional parameter for assessing the quality of life of individuals with different pathologies, in research and assistance.⁽³3 . Ciconelli RM, Ferraz MB, Santos WS, Meinão IM, Quaresma MR. [Brazilian-Portuguese version of the SF-36. A reliable and valid quality of life outcome measure]. Rev Bras Reumatol. 1999; 39(3):143-50. Portuguese.⁾ One of the health conditions evaluated in this study and associated with the SF-36 was the syndrome of physical frailty in older adults.

The syndrome of physical frailty can be defined as ‘a medical syndrome with multiple causes and contributions, which is characterized by a diminution of strength, endurance and reduced physiological function that increases the vulnerability of individuals and develops greater dependence and/or death’.⁽⁴4 . Morley JE, Vellas B, Kan AV, Anker SD, Bauer JM, Bernabei R, et al. Frailty Consensus: A call to action. JAMDA . 2013; 14:392-97.⁾ According to the authors, from this physical focus, frailty can be evaluated through five physical components: unintentional weight loss, reduced grip strength, decreased physical activity, self-reported fatigue and decreased gait speed. Older people who present three or more of these features are considered frail; those with one or two are pre-frail and those who do not have any of these components are non-frail seniors.⁽⁵5 . Fried LP, Tangen CM, Walston J, Newman AB, Hirsch C, Gottdiener J, et al. Cardiovascular Health Study Collaborative Research Group. Frailty in older adults: Evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001; 56A(3):146-56.⁾

Although the relations between aging, frailty and quality of life have been little explored, a recent number of studies connects the frailty syndrome with a worsened quality of life.⁽⁶6 . Fillit H, Butler RN. The frailty identity crisis. J Am Geriatr Soc. 2009; 57:348-52.^,77 . Bilotta C, Bowling A, Casè A, Nicolini P, Mauri S, Castelli M, et al. Dimensions and correlates of quality of life according to frailty status: a cross-sectional study on community-dwelling older adults referred to an outpatient geriatric service in Italy. Health Qual Life Outcomes. 2010; 8:56.⁾ Studies evaluating the frailty syndrome through the five physical components and the quality of life through the SF-36, observed that frail elderly had lower scores in almost all dimensions of quality of life when compared to other participants.⁽⁸8 . Masel MC, Graham JE, Reistetter TA, Markides KS, Ottenbacher KJ. Frailty and health related quality of life in older Mexican Americans. Health Qual Life Outcomes. 2009;23(7):70.

9 . Lin CC, Li CI, Chang CK, Liu CS, Lin CH, Meng NH, et al. Reduced health related quality of life in elders with frailty: A cross-sectional study of community-dwelling elders in Taiwan. Plos One. 2011; 6(7):e21841.^-1010 . Chang YW, Chen WL, Lin FG, Fang WH, Yen MY, Hsieh CC et al. Frailty and Its Impact on health-related quality of life: A cross-sectional study on elder community-dwelling preventive health service users. Plos One. 2012; 7(5):e38079.⁾ However, it is not yet a consensus that the frailty syndrome negatively influences the quality of life of individuals.

The frail elderly are vulnerable to unhealthy outcomes and therefore, they can express different combinations of quality of life. Little is known about the quality of life of Brazilian frail elderly, about the specific affected aspects, the deficits, the personal compensations and available resources. Hence, studies investigating the quality of life associated with frailty are needed. Through the results of these studies it will be possible to support a more independent life for elderly and to base preventive actions taken by health professionals, focusing on aspects related to frailty and quality of life.⁽¹¹11 . Gobbens RJ, Luijkx KG, Van Assen MA. Explaining quality of life of older people in the Netherlands using a multidimensional assessment of frailty. Qual Life Res. 2013; 22:2051-61.⁾

Given the above and the national deficit in studies that assess the frailty syndrome by the physical phenotype, the objective of this study was identifying the quality of life of frail elderly patients, users of primary care services.

Methods

This is a quantitative, cross-sectional study carried out in a Basic Health Unit, which is part of the primary health care service, located in Curitiba, state of Paraná, southern region of Brazil. The target population consisted of elderly aged 60 years and over, in the period between January and April 2013.

The following inclusion criteria were adopted for the selection of the elderly: a) age equal to or over 60 years; b) getting a score higher than the cutoff point (according to the level of education) in the cognitive test called Mini-Mental State Examination.⁽¹²12 . Folstein MF, Folstein SE, McHugh PR. “Mini-mental state”: a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975; 12(3):189-98.^,1313 . Bertolucci PH, Brucki SM, Campacci SR, Juliano Y. The Mini-Mental State Examination in a general population: impact of educational status. Arq Neuropsiquiatr. 1994;52(1):1-7.⁾ The exclusion criteria were: a) having previous diagnoses of diseases or serious physical and mental deficits that prevented the participation in the stages of interview and assessment of the frailty phenotype; b) having previously participated in the research.

This was a convenience sample and individuals were invited to participate in the study according to their order of arrival in the health service. The Mini-Mental State Examination was taken in a private environment for tracking the changes in cognitive function (cognitive screening) of the elderly.⁽¹²12 . Folstein MF, Folstein SE, McHugh PR. “Mini-mental state”: a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975; 12(3):189-98.^,1313 . Bertolucci PH, Brucki SM, Campacci SR, Juliano Y. The Mini-Mental State Examination in a general population: impact of educational status. Arq Neuropsiquiatr. 1994;52(1):1-7.⁾ In this study was used the validated version with the following cutoff points: 13 for illiterates, 18 for medium and low education and 26 for high levels of education.⁽¹³13 . Bertolucci PH, Brucki SM, Campacci SR, Juliano Y. The Mini-Mental State Examination in a general population: impact of educational status. Arq Neuropsiquiatr. 1994;52(1):1-7.⁾ The Mini-Mental State Examination comprises 11 items grouped into seven categories: temporal orientation, spatial orientation, registration of three words, attention and calculation, memory of three words, language and visual construction capacity. The scores range between zero and 30.

Data collection included the assessment of the frailty syndrome and evaluation of the health related quality of life of the elderly. In order to make the specificity of elderly Brazilians effective, two changes were made in the evaluation of measures of the frailty phenotype. According to American researchers and their collaborators, the Minnesota Leisure Activity Questionnaire is applied to identify the level of physical activity. For assessing the level of energy, specifically for the fatigue/exhaustion component, these authors use two questions of the Center for Epidemiologic Studies Depression Scale - CES-D.⁽⁵5 . Fried LP, Tangen CM, Walston J, Newman AB, Hirsch C, Gottdiener J, et al. Cardiovascular Health Study Collaborative Research Group. Frailty in older adults: Evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001; 56A(3):146-56.⁾ In the present study was applied the Level of of Physical Activity for the Elderly CuritibAtiva questionnaire for the physical activity component.⁽¹⁴14 . Rauchbach R, Wendling NM. Evolution of construction of an instrument to assess the level of physical activity for seniors – CuritibAtiva. FIEP Bulletin On-line. 2009; 79:543-7. Portuguese.⁾ The energy level was known through a question of the Geriatric Depression Scale - GDS, and by a graduated visual scale, using a numbered rule.⁽¹⁵15 . Almeida OP, Almeida SA. Reliability of the Brazilian version of the Geriatric Depression Scale (GDS) short form. Arq Neuropsiquiatr. 1999; 57(2B):421-6. Portuguese.⁾

The unintentional weight loss component was measured by the self-report of weight loss equal to or greater than 4.5 kg or 5% of body weight within the last year. The gait speed test was used to measure the slowness in seconds (distance of 4 m) with adjustment for gender and height. The handgrip strength was measured with a dynamometer in the dominant hand with adjustment for gender and body mass index - BMI.

The Medical Outcomes Study – MOS, Short Form 36 - SF-36, was used for assessing the health related quality of life. This is an instrument consisting of 36 questions; a question of comparison between the current and previous health, and 35 questions classified into eight domains: physical functioning, role-physical, bodily pain, general health, vitality, social functioning, role-emotional and mental health. The final score ranges from zero to 100, with higher scores indicators of positive health perception. The instrument was validated for the Portuguese language and is called “Brazil - SF-36”.⁽³3 . Ciconelli RM, Ferraz MB, Santos WS, Meinão IM, Quaresma MR. [Brazilian-Portuguese version of the SF-36. A reliable and valid quality of life outcome measure]. Rev Bras Reumatol. 1999; 39(3):143-50. Portuguese.⁾

The sample size was determined based on the estimate of population proportion. The confidence level was set at 95% (α = 0.05), 0.12 variance and sampling error was fixed at five percentage points. It was added 10% to the sample size, for the possibilities of losses and refusals, resulting in a sampling plan consisting of 203 elderly.

Data were organized in the Excel® 2007 program and the EpiInfo version 6.04 was used for statistical analysis of data: absolute and percentage frequency distribution, mean and standard deviation.

The development of study followed the national and international standards of ethics in research involving human beings.

Results

The study included 203 elderly patients, of whom 39 (19.2%) were classified as frail, 115 (56.7%) as pre-frail and 49 (24.1%) as non-frail.

The highest mean score for quality of life of frail elderly was for the psychosocial dimensions - concerning social aspects, emotional aspects, vitality and mental health. The lowest mean score was for the physical dimensions - concerning pain, functional capacity, limitations due to physical aspects and general state of health (Table 1).

The quality of life of frail elderly by position is shown in chart 1. It is observed that the pain dimension of quality of life is the worst evaluated and the social aspect dimension is the best evaluated.

Discussion

The limits of the study results are related to the cross-sectional design that does not allow establishing relations of cause and effect. On the other hand, the results could guide gerontological nursing care in the practice with frail, pre-frail and non-frail elderly. The studies on the syndrome of frailty and quality of life of seniors subsidize the provision of care for successfully combating the frailty, and consequently resulting in improved quality of life for these individuals.

When compared to national and international studies, the frequency distribution of frailty in this study is significantly high (19.2%). A study with 606 Americans aged 65 years or more, in which 301 participants were of Mexican ancestry and 305 of European descent, found 12.2% and 7.3% of frail elderly, respectively.⁽¹⁶16 . Espinoza SE, Jung I, Hazuda H. Lower Frailty Incidence Among Mexican American than Among European American Older Adults: The San Antonio Longitudinal Study of Aging. J Am Geriatr Soc. 2010; 58(11):2142-8.⁾ Another study carried out in Spain with a sample of 814 elderly (aged 65 years or more), found 10.3% of frail elderly.⁽¹⁷17 . Alcalá MV, Puime AO, Santos MT, Barral AG, Montalvo JI, Zunzunegui MV. Prevalence of frailty in an elderly Spanish urban population. Relationship with comorbidity and disability. Aten Primaria. 2010; 42(10):520-7.Spanish.⁾ The pioneering study carried out in Brazil on Frailty in Brazilian Elderly, consisting of a sample of 3,413 individuals aged 65 years or over, revealed 9.1% of frail elderly.⁽¹⁸18 . Neri AL, Yassuda MS, Araújo LF, Eulálio MC, Cabral BE, Siqueira ME, et al. Methodology and social, demographic, cognitive, and frailty profiles of community-dwelling elderly from seven Brazilian cities: the FIBRA Study. Cad Saúde Pública. 2013; 29(4):778-92. Portuguese.⁾

The cultural difference is considered a determining factor. Researchers claim that the unequal distribution of frailty in different places, besides reflecting possible differences in health between countries and regions, can also be attributed to the cultural characteristics that influence the perception of health and interpretation of subjective items of the scales used to assess frailty.⁽¹⁹19 . Santos-Eggimann B, Cuénoud P, Spagnoli J, Junod J. [Prevalence of frailty in middle-aged and older community-dwelling Europeans living in 10 countries]. J Gerontol A Biol Sci Med Sci. 2009; 64(6):675-81.⁾ Issues relating to lifestyle, nutrition, hydration, presence of comorbidities and medication use may also have influenced the divergence of results.

The dimensions of quality of life of the frail elderly most affected by the frailty syndrome resemble those found in the research conducted with a sample of 1,008 American elderly of Mexican descent aged 74 years or more.⁽⁸8 . Masel MC, Graham JE, Reistetter TA, Markides KS, Ottenbacher KJ. Frailty and health related quality of life in older Mexican Americans. Health Qual Life Outcomes. 2009;23(7):70.⁾ The study on the relation between the frailty syndrome and the quality of life of older people using the Medical Outcomes Study - MOS Short Form 36, concluded that the frail elderly of the sample had lower mean scores in the aspects of functional capacity, limitations due to physical aspects and general state of health.

The biological nature of the frailty syndrome itself justifies the significant deficit in the physical dimension of quality of life of frail elderly. In the cycle of frailty, physical problems such as sarcopenia, multiple diseases, excessive use of medication, and neuroendocrine deregulations are directly related with frailty and, consequently, affect the quality of life of these individuals. Moreover, the decline of different physical components that occurs in the syndrome may contribute to this result. Studies have shown that the decrease in physical activity,⁽²⁰20 . Paskulin L, Vianna L, Molzahn AE. Factors associated with quality of life of Brazilian older adults. Int Nurs Rev. 2009;56(1):109-15.^,2121 . Timm LA, Argimon IIL, Wendt GW. Correlation between domains of quality of life and locus of health control in community resident elderly. Sci Med. 2011;21(1): 9-13. Portuguese.⁾ handgrip strength,⁽⁹9 . Lin CC, Li CI, Chang CK, Liu CS, Lin CH, Meng NH, et al. Reduced health related quality of life in elders with frailty: A cross-sectional study of community-dwelling elders in Taiwan. Plos One. 2011; 6(7):e21841.^,1010 . Chang YW, Chen WL, Lin FG, Fang WH, Yen MY, Hsieh CC et al. Frailty and Its Impact on health-related quality of life: A cross-sectional study on elder community-dwelling preventive health service users. Plos One. 2012; 7(5):e38079.⁾ gait speed⁽⁹9 . Lin CC, Li CI, Chang CK, Liu CS, Lin CH, Meng NH, et al. Reduced health related quality of life in elders with frailty: A cross-sectional study of community-dwelling elders in Taiwan. Plos One. 2011; 6(7):e21841.^,1010 . Chang YW, Chen WL, Lin FG, Fang WH, Yen MY, Hsieh CC et al. Frailty and Its Impact on health-related quality of life: A cross-sectional study on elder community-dwelling preventive health service users. Plos One. 2012; 7(5):e38079.⁾ and energy⁽²2 . Molzahn A, Skevington SM, Kalfoss M, Makaroff KS. The importance of facets of quality of life to older adults: an international investigation. Qual Life Res. 2010; 19:293-8.^,99 . Lin CC, Li CI, Chang CK, Liu CS, Lin CH, Meng NH, et al. Reduced health related quality of life in elders with frailty: A cross-sectional study of community-dwelling elders in Taiwan. Plos One. 2011; 6(7):e21841.⁾ are directly related to decreased quality of life. Identifying the components of frailty associated with the quality of life of frail elderly is an important first step, as it will lead to the early detection of the involved problems and the establishment of interventions and preventive actions.⁽¹¹11 . Gobbens RJ, Luijkx KG, Van Assen MA. Explaining quality of life of older people in the Netherlands using a multidimensional assessment of frailty. Qual Life Res. 2013; 22:2051-61.⁾

Unlike other studies, the dimension of pain had the lowest mean score of all investigated dimensions (60.4 points).⁽⁸8 . Masel MC, Graham JE, Reistetter TA, Markides KS, Ottenbacher KJ. Frailty and health related quality of life in older Mexican Americans. Health Qual Life Outcomes. 2009;23(7):70.^,1010 . Chang YW, Chen WL, Lin FG, Fang WH, Yen MY, Hsieh CC et al. Frailty and Its Impact on health-related quality of life: A cross-sectional study on elder community-dwelling preventive health service users. Plos One. 2012; 7(5):e38079.⁾ Pain in aging is related to symptoms that are precursors of decline of health and of bodily functions. Physical changes inherent to the frailty of the elderly can be associated with a reduction in health related quality of life, with the lowest mean scores for the pain dimension of the SF-36.⁽⁹9 . Lin CC, Li CI, Chang CK, Liu CS, Lin CH, Meng NH, et al. Reduced health related quality of life in elders with frailty: A cross-sectional study of community-dwelling elders in Taiwan. Plos One. 2011; 6(7):e21841.⁾ The early identification of pain and the use of analgesic drugs may be important factors in the prevention of frailty and increase in quality of life.

A study shows that physical activity practice can improve the condition of frailty in the elderly and therefore, functional capacity.⁽²²22 . Cameron ID, Fairhall N, Langron C, Lockwood K, Monaghan N, Aggar C, et al. A multifactorial interdisciplinary intervention reduces frailty in older people: randomized trial. BMC Medicine. 2013; 11:65.⁾ Thus, prescriptions for physical activity according to the possibility of individuals, could act both in the prevention of frailty syndrome as in improving the quality of life of frail elderly. Also, engaging in physical activity can improve mental health and promote social contacts,⁽²⁰20 . Paskulin L, Vianna L, Molzahn AE. Factors associated with quality of life of Brazilian older adults. Int Nurs Rev. 2009;56(1):109-15.⁾ which is also beneficial for the psychosocial dimensions of the quality of life of seniors.

The psychosocial dimensions have obtained the best scores in the quality of life of frail elderly, a result of the social relations maintained by most of them. The main feature of the psychosocial profile is to be living with relatives or with the spouse and not feeling alone. Many Brazilian elderly still have an important role in the maintenance of themselves and their families.⁽²⁰20 . Paskulin L, Vianna L, Molzahn AE. Factors associated with quality of life of Brazilian older adults. Int Nurs Rev. 2009;56(1):109-15.⁾ These factors lead the elderly to maintain an active social life, reducing isolation, dependency, thus obtaining better scores on quality of life regarding the psychosocial dimensions. Risk factors involving social relations are strongly associated with moderate or severe dependence. Although the frailty syndrome is a risk factor for dependence, maintaining social relationships can reduce or postpone this scenario.

A national study carried out with 113 participants aged between 60 and 98 years found that seniors with a routine concern with their network of friends and family had better quality of life.⁽²¹21 . Timm LA, Argimon IIL, Wendt GW. Correlation between domains of quality of life and locus of health control in community resident elderly. Sci Med. 2011;21(1): 9-13. Portuguese.⁾ According to the author, the ability of the elderly to remain active in the society and for their loved ones transcends the limitations and physical disabilities, while the inability to alter the physical environment becomes inefficiency, lack of motivation and lower levels of quality of life.

Conclusion

The frail elderly had lower mean scores for the physical dimensions of quality of life such as pain, functional capacity, limitations due to physical aspects and general state of health. The highest mean scores were obtained in psychosocial dimensions, concerning social aspects, emotional aspects, vitality and mental health.

Acknowledgements

Research carried out with the Support of Scientific and Technological Development of Paraná – Fundação Araucária (FA), under protocol number 18239, contract 005/2011.

References

Publication Dates

History