ABSTRACT

The aim of the present study was to describe the conceptual and operational definitions of the frailty syndrome recommended by the Brazilian Consensus on Frailty in Older People. In 2015, a task force consisting of Brazilian specialists on human aging conducted a bibliographical review on frailty among older people in Brazil and established a consensus on the main findings through periodic meetings. A total of 72 articles were included in the analysis, comprising one systematic review, two conceptual discussions, two methodological descriptions, four longitudinal studies focusing on mortality and worsening of the frailty profile, eight cross-cultural adaptation studies, and 55 cross-sectional or prevalence studies. Forty-five studies (62.5%) used the Cardiovascular Health Study (CHS) frailty scale, of which seven (15.2%) used unadjusted cut-off points for their samples and 17 (36.9%) modified at least one of the five items of the instrument. The prevalence of frailty varied between 6.7 and 74.1%. When the CHS frailty scale was used, the wide range of prevalence — from 8 to 49.3% — depended on the cut-off points used to classify changes in gait speed and handgrip strength, as well as the research setting. The studies were based on four major conceptual models of frailty. Frailty in older people represents a state of physiological vulnerability and should not be confused with disabilities or multi-morbidities. In the Brazilian population, the prevalence of frailty has not yet been adequately estimated, and the cut-off points of the items of the frailty scales should be adapted to the parameters of this population.

Keywords: aging; aged; health of the elderly; health vulnerability; frail elderly.

RESUMO

O objetivo do presente trabalho foi descrever as definições conceitual e operacional da síndrome de fragilidade recomendadas pelo Consenso Brasileiro de Fragilidade em Idosos. Em 2015, uma força-tarefa composta de especialistas brasileiros em envelhecimento humano conduziu uma revisão bibliográfica sobre fragilidade em idosos no Brasil e estabeleceu um consenso acerca dos principais achados por meio de reuniões periódicas. No total, 72 artigos foram incluídos para análise, entre os quais, uma revisão sistemática, duas discussões conceituais, duas descrições metodológicas, quatro estudos longitudinais focando mortalidade e piora do perfil de fragilidade, oito estudos de adaptação transcultural e 55 estudos transversais ou de prevalência. O Quarenta e cinco estudos (62,5%) utilizaram a escala de fragilidade do Cardiovascular Health Study (EFCHS), dos quais sete (15,2%) usaram pontos de corte não ajustados para a amostra e 17 (36,9%) modificaram pelo menos um dos cinco itens que compõem o instrumento. A prevalência de fragilidade variou entre 6,7 e 74,1%. Quando utilizada a EFCHS, a ampla variação de prevalência — de 8 a 49,3% — dependeu dos pontos de corte empregados para classificar as alterações na velocidade de marcha e na força de preensão palmar, bem como do cenário de investigação. Os estudos foram baseados em quatro grandes modelos conceituais de fragilidade. A fragilidade em idosos representa um estado de vulnerabilidade fisiológica e não deve ser confundida com incapacidades ou multimorbidades. Na população brasileira, a prevalência de fragilidade ainda não está adequadamente estimada, e os pontos de corte dos itens que compõem as escalas de fragilidade devem ser adaptados aos parâmetros dessa população.

Palavras-chave: envelhecimento; idoso; saúde do idoso; vulnerabilidade; fragilidade; idoso fragilizado.

INTRODUCTION

Frailty is a nonspecific state of increased risk of mortality and adverse health events such as dependence, disability, falls and injuries, acute illness, slow recovery from illness, hospitalization, and long-term institutionalization.^1,2 In the elderly population, frail individuals are those most in need of health care, and, thus, frailty can be used as a potential organizer for older people health management.³

Given the rapidly aging population in our country, a consequence of demographic and epidemiological transitions, the number of frail individuals is increasing rapidly.⁴ In high-income countries, depending on the population evaluated, 10-25% of people aged 65 or over may be classified as frail,⁵ and many forms of geriatric healthcare, such as comprehensive evaluations, preventive interventions and multidisciplinary care, are targeted for frail individuals, since, in this group, these proceedings have better cost-effectiveness. Thus, when establishing investment priorities that align financial and quality of life conditions, the frail individual should be considered the primary target of health policies directed at the elderly population.^6-9

Among the various conceptual models of frailty,¹⁰ reduced functional reserve, which involves multiple organ systems, has gained better acceptance among researchers in the field.¹¹ In this model, frailty represents a state of heightened physiological vulnerability of heterogeneous presentation that is associated with chronological age and reflects multisystemic physiological changes that affect homeostatic adaptability. The most commonly used scale for instrumentalizing this definition consists of items that assess nutritional status, energy expenditure, physical activity, mobility and muscle strength.¹¹

Another conceptual model is deficit accumulation, which is based on the sum of limitations and diseases and emphasizes the number of disorders rather than their nature. The instrument based on this model defines frailty using at least 30 variables, including disabilities and comorbidities.¹²

The third conceptual model is multidimensional, characterizing the condition as a dynamic state of loss that affects one or more areas, such as cognitive, physical and social domains.^13-17 Finally, another series of measurement instruments are primarily based on functional disability.^18,19

In Brazil, the diversity of conceptual and operational models has produced questions among those involved in geriatric health issues. Such questions include: areas of research — how best to investigate frailty; teaching — how to inform undergraduate and graduate students and health professionals; and care — how to identify and treat frail individuals in public and private health care networks.

This article describes the results of the discussions by Brazilian specialists in human aging organized on the Brazilian Consensus on Frailty in Older People (Consenso Brasileiro de Fragilidade em Idosos — CBFI) task force. The objective was to establish a national consensus about indicators for determining the epidemiological frequency of frailty syndrome in Brazil, as well as conceptual and operational definitions that could guide care, teaching and research by Brazilian geriatrics and gerontology professionals.

METHODS

Creation of the Brazilian Consensus on Frailty in Older People

The CBFI was created by a decision of ten academic institutions in geriatrics and gerontology that had been meeting in monthly teleconferences (TeleGero) since July 2005 to discuss issues related to human aging. During the September 2015 TeleGero meeting, based on a proposal by one member that was unanimously accepted, a committee of experts was formed to define the CBFI’s working methodology.

Following this meeting, a task force was formed with a variable number of members from each academic institution participating in TeleGero, as well as professionals from other institutions whose professional interest and/or care, teaching, research or management activities were related to frailty syndrome in older people.

The task force developed its activities through monthly teleconferences, electronic message exchange and a face-to-face meeting in 2016 in Fortaleza, Ceará, Brazil, during the XX Brazilian Congress of Geriatrics and Gerontology.

The problem to be addressed and the objectives of the CBFI task force

The criteria and conceptual and operational diversity of the instruments used to screen/diagnose the frailty syndrome are reflected in the following areas:

• healthcare: the difficulties that public and private health managers have in selecting population screening instruments;

• teaching: the difficulties in adequately training specialized professionals in geriatrics and gerontology;

• research: the difficulties in comparing results among different research settings and populations that inhabit Brazil.

Division of CBFI by theme

The members of the task force were subdivided into five groups, each responsible for one of the following thematic areas: conceptual definition; epidemiology; physiopathology; evaluation and diagnostic tools; prevention and treatment. Initially, each group worked independently and, subsequently, virtual meetings were held to integrate the information.

Narrative review and expert opinion

It was decided to conduct a narrative review of the five thematic areas by searching for articles published in scientific journals between January 2009 and August 2017 that addressed frailty syndrome in Brazilian population samples. The main reference databases — PubMed and the Scientific Electronic

Library Online — were searched using the (English) MeSH keywords frail, aged, frail elderly, elderly, Brazil, elders, older, and older adults, connected by the Boolean operators AND and OR.

The task force members discussed the main findings and conclusions until reaching a consensus about each theme. These positions were discussed during the development of this report until the final text was produced, which involves some of the epidemiological and conceptual questions and assessment instruments pertinent to national scientific research and production. A future document will describe the other aspects of the thematic areas addressed by the task force.

RESULTS AND DISCUSSION

Epidemiological aspects

The database search found 201 articles, while a manual search for authors with publications in the field of aging and previously known bibliographic references identified another 24. Of this total, 193 articles (Figure 1) met the initial screening criteria. After title and abstract analysis, 79 of these were excluded, leaving 115 articles for full text assessment. Of these, 42 were excluded for one of the following reasons: being integrative reviews, being case reports or lacking descriptive data on frailty. Thus, a total of 72 articles were included in the analysis, including one systematic review, two conceptual discussions, two methodological descriptions, four longitudinal studies focusing on mortality and worsening of the frailty profile, eight cross-cultural adaptation studies and 55 cross-sectional or prevalence studies (Annex 1).

Figure 1 Selection flowchart for frailty studies with Brazilian population samples. Brazilian Consensus on Frailty in the Elderly, 2017.

The study samples were selected from several settings. Three came from long-term care institutions for older people, five from hospital units, eight from outpatient clinics and 52 from community-dwelling populations. No research scenarios were presented in the four papers on methodology and concepts.

Regarding the instruments used to evaluate frailty, one study used a frailty index, one used the Clinical-Functional Vulnerability Index-20, one used an instrument developed by the Brazilian Ministry of Health, one used a self-report instrument, three used the Tilburg Frailty Indicator, three used the Kihon Checklist, three used the FRAIL scale (FS) and nine used the Edmonton Frail scale. Forty-five studies (62.5%) used the Cardiovascular Health Study (CHS) frailty scale, of which seven (15.2%) used unadjusted cut-off points for their sample and 17 (36.9%) modified at least one of the items of the instrument (Annex 1).

The prevalence of frailty in a 2016 systematic review ranged from 7.7 to 42.6%.²⁰ In our review, this number was between 6.7 and 74.1%. The main sources of variation were the instrument used to classify individuals as frail and the assessment setting. When the CHS frailty scale was used, the broad prevalence range — from 8 to 49.3% — depended on the cutoff points used to classify the research setting (community, hospital, ambulatory or long-term care), changes in gait speed and handgrip strength.

Conceptual aspects

The instruments identified in this report used four major conceptual models of frailty and, corroborating the international literature, the CHS frailty scale was the most commonly applied instrument in Brazilian studies. The use of so many different instruments led to uniformity difficulties among the prevalence rates. The significant variation indicates that there is an expressive limitation on the results and the comparisons that can be made between them. The need for standardizing the model, and especially the diagnostic tool, is one of the challenges to identifying the frail elderly, and, in the light of the present consensus, still needs scrutiny. However, all of the studies, regardless of the model used, were unanimous in pointing out the urgent need to identify frailty syndrome, given its innumerable negative outcomes.

Evaluation instruments

Among the instruments observed in the present study, some valued the multidimensional aspects of older people (social, psychological, and cognitive), while others dealt exclusively with the physical elements of frailty. A clear distinction could be seen between these instruments and, from the point of view of definition, two major models were used: the vulnerability and the physiological frailty models. This issue permeated the discussion while this study was being prepared and will be the exclusive subject of a subsequent publication. In simplified terms, it was concluded that vulnerability is a comprehensive term that encompasses numerous dynamic dimensions — physiological, psychological, cultural and social.²¹ Physiological frailty, as defined by Buchner and Wagner,²² is a state of organic vulnerability, associated with aging and triggered by stressful events, in which an imbalance of homeostatic mechanisms occurs, promoting a negative spiral of undesirable events. With advancing age, the prevalence of comorbidities and limitations to functional capacity increases. Although these conditions usually accompany physiological frailty, they are distinct from it.²³

Regarding instruments based on the physiological frailty model, especially the CHS frailty scale, it was observed that, even with five well-defined criteria — handgrip strength, gait speed, feeling of exhaustion, caloric expenditure and weight loss

— many studies resorted to cut-off points that were not adapted to their respective studies, specifically for the first two criteria. In addition, other studies chose to use only four of the five proposed criteria due to the existing limitations and diagnostic difficulties for this condition. Modifying these items leads to even further limitations in adequately identifying frailty in clinical practice.

CONCLUSIONS

The task force agreed on the following definitions and recommendations for care, teaching and research:

• frailty represents an age-related physiological vulnerability, produced by diminished homeostatic reserve and the organism’s reduced ability to cope with a variety of negative health outcomes, including hospital admissions, falls, and functional loss, which increases the likelihood of mortality;

• frailty should not be confused with disability, non-physiological vulnerability or multimorbidity;

• every health professional who assists older people must be familiar with frailty syndrome and its consequences;

• there is insufficient evidence to establish population strategies for frailty syndrome screening in the general elderly population. However, the task force considers that recognition of this syndrome is important, since it identifies elderly individuals at greater risk of unfavorable outcomes and, consequently, can impact individualized care;

• the FS and CHS frailty scale address frailty syndrome. The Edmonton, Tilburg and Kihon scales involve the concept of vulnerability. Studies should apply instruments that are relevant to their research objective: to identify the frail elderly or the vulnerable elderly;

• although normative data are not available for the Brazilian population, the cut-off points of frailty scale items, such as gait velocity and handgrip grip strength, should be adapted for the study population.

• Brazilian researchers should investigate simpler methods of identifying frailty syndrome that facilitate use in both specialized care settings, such as geriatrics clinics, and primary health care.

ACKNOWLEDGEMENTS

The ideas expressed in this document represent views of the members of the CBFI task force; they do not necessarily coincide with those of the consultants (listed below). The authors would like to thank the professionals, professors and researchers who have lent their time and knowledge in expressing their expert opinions.

Consultants: Anita Liberalesso Neri, José Elias Pinheiro, Tarso Mosci, Sergio Telles Ribeiro Filho, Elisabeth Vianna de Freitas, Luiz Garcez-Leme, Marcos Aparecido Sarria Cabrera, João Bastos Freire, Paulo Villas Boas, Einstein Camargos.

CONFLICT OF INTERESTS

The authors declare no conflicts of interest.

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Received in April 10 2018.
Accepted em April 11 2018.