Ageing leads to coexistence of several pathological conditions producing a negative impact on health status that may lead to frailty (Richter et al., 2021). Frailty is considered to be a serious public health concerns that results in severe adverse health outcomes as decrease quality of life, functional disability, increase hospitalization and death rate (Lyu, Wang, Jiang, Wang, & Cui, 2021).The importance of studying frailty comes from the fact that it is merely associated with aging and not an inevitable process; hence, it can be prevented or treated. Unfortunately, frailty prevalence among the elders in Egypt is barely known (Naeem et al., 2020). Therefore, this study aimed to study the prevalence and associated factors of frailty among community dwelling older adults.
In studying frailty prevalence, we found that according to the SHARE frailty index, around 64.7% of the 300 elderly participants were considered as frail, whereas 30% were prefrail and only 5.3% were robust (non frail). The high frailty prevalence in the current study may not be surprising but rather expected for many reasons; first, the fact that our study was carried out in two settings, urban and rural areas may partly explain this high prevalence. In deed the elderly population in our study may be more vulnerable because of due to the lower socioeconomic status and limited access to health care services which have been associated with frailty. Finally, most of the geriatric syndromes and factors attributing to the development of frailty were very common in the studied older adults.
Previous studies reported slight differences in prevalence rates of frailty among elderly people; study done in Egypt by Gasser, Elbanouby, Abou-Hashem, &Maamoun (2020) showed that the prevalence of frailty and pre-frailty was 48% and 22.1% respectively according to the clinical frail scale, Sabbour et al (2018) depicted that71.7% of the 350 elderly participants were considered as frail, whereas 22.6% were considered as prefrail and only 5.7% as robust and Tayel and Elkady(2016) where they found that 58.7% of the elderly residents in geriatric homes were frail.
Whilst many other studies reported a much lower rate, the prevalence of frailty was 33.5% in the study of Naeem et al., (2020) in Egypt, 26%in the study of Rivas-Ruiz et al., (2019) in Spain, 34% in the study of Thompson et al., (2018) in Australian. However, recent systematic review report the prevalence of frailty to be 14.6% (95% CI = 10.9% to 18.8%) according to the Fried frailty phenotype (To, Doan, Ho, & Liao, 2022).The difference between our study and other studies may be due to many factors including study settings "eg: our sample were collected from community and other studies collected participants from geriatric homes or outpatient clinic", study population, sample size, and assessment tools. There is an association between all these factors and the different risk of frailty and prefrailty among the elderly (Ofori-Asenso et al., 2018).
The present study revealed that frailty encountered more with increasing age and in female older adults with significant relation. This may be due to the hypotheses of the fact that females live longer than males. The physiological changes, co-morbidity and disability that occurs along body systems that accompanied aging make older females more-frail than male (Gordon et al., 2017).This result in agreement with the studies done in Korea by Kim, Yang, & Kim, (2021), in Latin America by Da Mata et al., (2021), and in Italy, by Collins et al., (2020), in U.S. by Denfeld et al., (2021), in China by Zhang et al., (2020).On the other hand, studies done in Korea by Kim et al., (2021), in Malaysia by Norazman, Adznam, &Jamaluddin, (2020), found no association for frailty and sex despite of the higher percentage of frailty in female than in male.
Living alone, being widow and lower socioeconomic status (SES) as measured by low education and/or low income and occupation, has been was correlating with frailty in this study. Similar findings were reported in prior studies; study done in China by Kong, Lyu, Yao, Yang, & Chen, (2021), meta-analyses from studies done by Kojima, Walters, Iliffe, Taniguchi, & Tamiya, (2020), and by Kojima, Taniguchi, Kitamura, & Fujiwara, (2020), showed that being unmarried were have a twice risk to be frail than being married, studies done in Italy by Salaffi, Di Carlo, Carotti, Farah, &Giovagnoni, (2021), in Spain by Soler-Vila et al., (2016), which found relationship between lower educational level and frailty, study done in Egypt by Saudi, Tosson, &Salama, (2021), in China by Zhang et al., (2020), and in Belgium Maseda et al., (2018) found that those elderlies with low income were frail. Moreover, Van der Linden (2020) in Switzerland, and Srivastava, &Muhammad (2022) in India found positive relationship between lower SES and development of frailty in elderly.
Frailty was found to be linked to various risk factors among which is the comorbidities and polypharmacy. When assessing medical history of the studied older adults via self-reported number of diagnosed chronic diseases and number of medications used, it was found that the majority of those who had more than one disease, and who took more than 5 medications were frail with highly statistically significant association. This may be justified by the fact that geriatric comorbidities courses decline in many physiological systems in older adults that leads to homeostatic imbalance or frailty and increased risk to adverse drug events and medication-related harm (Liau et al., 2021).In the line with current result, studies done in Egypt by Saudi et al., (2021), Gasser et al., (2020) in India by Panda, Pathak, Islam, Agarwalla, Singh, & Singh, (2020).
Moreover, the prevalence of frailty was higher among older adult who not engage in social practice, ex-smoker and intake caffeine daily in the current study. This result supported by; study done in China by Wang, Chen, & Zhou, (2021)& in Korea by Chon, Lee, Kim, & Lee,(2018)which revealed that participating in social activities had a significantly lower frailty risk than participants who never engaging in those activities. Contrariwise, studies done in Canada by Verschoor et al., (2021), in Korea by Jung, Lyu, & Kim, (2021), in China by Li, Xue, Odden, Chen, & Wu, (2020), found that the majority of those who were current-smoked, were frailer but without statistically significant association. In inverse, study done in China by Jing et al., (2020), found that non-tea drinkers were more likely to frailty than tea drinkers, and in Spain by Machado-Fragua, Struijk, Graciani, Guallar-Castillon, Rodríguez-Artalejo, F., & Lopez-Garcia, E. (2019), and by Brunelli et al., (2021), showed no association between coffee/tea consumption/day and frailty.
The present results found negative correlation between body weight, & body mass index (BMI), HGS, mid-arm circumference (MAC), and calf circumference (CC) of the studied older adults with frailty. This result may be because of those who with week hand grip strength reduced their physical ability and increased their fragility which were considerable factors in the frailty, and those with too low body weight also had decreased in overall strength.In the line with the current results, studies done in China by Yuan, Chang, & Wang, (2021), in San Francisco by Lai, Dodge, McCulloch, Covinsky, & Singer, (2020),and in Australia by Tembo et al., (2020), shown that BMI were associated with frailty. In the agreement with current results, studies done in Egypt by Naeemet al., (2020), and in Italy by Valentini, Federici, Cianfarani, Tarantino, &Bertoli, (2018), found statistical correlation between frailty and hand grip strength. In the accordance to present results, study done in China by Liang, Li, Lin, Ju, &Leng, (2021) found that, there was statistically association was found with MAC & CC.
Disability is historically known as having difficulty in performing the essential activities to independent living i.e. difficulties in performing activities of daily living (ADL) and/or instrumental activities of daily living (IADL). Frailty is a well-known predictor of disability (Kojima, 2017). Supporting this, the current study showed that, older adults who were frail were dependent in ADL and IADLs, with statistically significant association between frailty and AD& IADL. Similar result was reported by the study done in Egypt by Saudi et al., (2021),&Naeem et al., (2020)and in Sri Lanka by Siriwardhana, Weerasinghe, Rait, Scholes, & Walters, (2020), showed that frailty was significantly associated with ADL and IADL.
When studying frailty and nutritional status, a strong negative association between frailty and malnutrition was found. Thus, among frail studied older adults, the majority had poor nutritional status. This finding points toward the fact that malnutrition usually occurs due to inability to regulate nutritional needs, or poor absorption of nutrients, and then lead to sever weight loss, state of easy fatiguability, tired, exhausted, increased vulnerability and lack power that end by increased vulnerability or frailty and vice versa, alongside the significant association of poor oral health with frailty that found by Bassim et al., (2020). Further studies were in the line with the present result, study done in Egypt by Shokry, Hamza,Fouad, Mohammed, &Aly, (2021) &Sabbour et al., (2018),in China by Zhang, Zhang, Hu, Meng, Xi, Xu, & Yu, (2021),Zhang et al., (2020), their analysis showed that, malnutrition was significantly associated with frailty. Similarly, study done in Korea by Seo et al., (2021), and in Netherlands by Benraad, (2021), found negative correlation of frailty with nutritional status.
Present study revealed that age, current work, comorbidities, polypharmacy, IADL and nutritional status were significant independents predictors for frailty. Similarly, studies done in China, by Xu et al., (2021), found age, multimorbidity, and IADL scores showed significant associations with frailty (all P < 0.05),in Indonesia by Setiati et al., (2019), found age as predictors for frailty, and in Italy, by Valentini et al., (2018), found IADL predictors for frailty. This result may be justified as older adults are at greater risk of iatrogenic events due to the age-related functional deficits, disease progression, comorbidities, and polypharmacy. Also older adults complain limited physical activity, feel exhausted, lack energy, and weight loss. All these conditions make older adults more prone to frailty syndrome (Muacevic et al., 2021).
In the light of the finding of this study and the fact that frailty is a highly prevalent syndrome in aging populations, it is essential to assess and manage frailty properly. In this regard, knowledge about frailty-associated factors and the complexity of their determinants support the construction of early preventive and intervention measures (Pegorari, & Tavares, 2020).
Strength and limitation:
To our knowledge, researches in frailty are rarely covered in the developing countries, especially in Egypt. This study highlighted frailty as critical problems for older adults which will contribute to the literature on frailty among older adults in Egypt; the study evaluated an extensive list of sociodemographic factors, lifestyle and health relevant, and clinical characteristics, functional, nutritional status, that could influence the frailty among community-dwelling older adults. The study was conducted in 6 geographical regions (3 urban and 3 rural areas) in Dakahlia, which may result in the generalizability of the findings. However, there are some limitations. First, cross-sectional study design may limits the ability to conclude the direction of causality. Second, self reported information in the questionnaire may be affected by memory and information bias due to educational inequality.