Prevalence and associated factors of frailty among community dweller older adults living in Gondar town, northwest, Ethiopia: A community based cross-sectional study.

Abstract

Background: Frailty is a multidimensional geriatric condition that increases vulnerability to stressors, increases the risk of negative health outcomes, and lowers quality of life in older people. However, little attention has been paid to frailty in developing countries, particularly in Ethiopia. Therefore, this study aimed to investigate the prevalence and identify the contributing factors of frailty.

Methods: A community-based cross-sectional study design was conducted from April to June 2022. A total of 607 study participants were included using a single cluster sampling technique. Data was collected by interviewing the participants using a structured questionnaire, and a pretest was conducted. Tilburg frailty indicator was used to measure frailty among older adults. Data was analyzed using descriptive statistics, binary and multivariate logistic. Variables with a P-value of less than 0.25 in the bivariate logistic regression were entered into a multivariable logistic regression model. Finally, variables with an odds ratio, a 95% confidence interval, and a P value less than 0.05 had a significant association were reported.

Results: In this study the overall prevalence of frailty among older adults was 39% (CI 95%, 35.51-43.1). Older age (AOR=6.26 CI (3.41-11.48), presence of two or more morbidity (AOR = 6.05 CI (3.51-10.43), activity of daily life dependency (AOR = 4.12 CI (2.49-6.80), and depression (AOR = 2.68 CI (1.55-4.63) were found to be significant factors.

Conclusion and recommendations: The prevalence of frailty was found to be remarkable, and we conclude that frailty should be recognized as a priority public health problem among older adults in the study area. Therefore, it is important to focus on educating the older adult population about healthy aging and orienting them on these modifiable risk factors should be considered to mitigate the problem.

Background

According to the world health organization report, the global population of older adults aged 60 years or more is expected to rise to around 2 billion by 2050 (1).This aging population in Ethiopia in 2015 was 5.2 million, accounting for more than 5% of the total population, and is expected to rise to 6.1% in 2030 and 10.4% in 2050 (2) .

Human aging is a dynamic and progressive natural process which is depends on interacting hereditary, biological, social, environmental, historical and cultural factors that determine the quality of life of an older individual (3).The concept of frailty is defined by the inability to maintain homeostasis in response to even minor stressors, in which these changes accumulate to the degree where they may cause increased levels of vulnerability and a decline in quality of life among older adult population (4).

Frailty is a multidimensional geriatric condition that increases vulnerability to stressors, increases the risk of negative health outcomes, and lowers quality of life, making it one of the most difficult challenges for health care in an aging society (5–7).

Prevalence of frailty is present in millions of older adults worldwide however, the global prevalence of frailty is not yet known, partly because frailty research has predominantly been done in high-income countries (8). A systematic review conducted in 2012, the weighted prevalence of frailty in high income countries was 10.7% (9).Another systematic and meta-analysis of studies from different populations in low and middle-income countries based on 2007 World Bank income category has reported that the prevalence of frailty among older adults varied from 4% in China to 51% in Cuba (10).

Frail older adults are at increased risk of premature death and various negative health outcomes, including falls, fractures, disability, and dementia, all of which could result in poor quality of life and increased cost and use of health care resources, such as emergency department visits, hospitalization, and institutionalization (11–14). Studies done among community-dwelling older adults have shown that the healthcare costs of frail individuals are sometimes several-fold higher than those of non-frail counterparts (15, 16).

Risk factors for the onset of frailty or frailty progression span a wide range of aspects and conditions, covering socio-demographic, clinical, lifestyle-related, and biological domains (17). Previous studies conducted among older adults showed that increasing age, female gender, living alone, low educational level, low income status, depression, morbidity, and low level of physical activity are very much associated factors with frailty (18–23).

In fact, frailty is regarded as a pre-disability state and, therefore, if early detection of frailty and identifying risk factors on time could guide public health and preventive strategies, in particular when these risk factors are potentially modifiable by specific interventions(8).

Generally frailty is considered as a dynamic condition, with proper interventions frailty can be altered or prevent many adverse health outcome in the older people leading to good mental and physical health and satisfaction quality of life (24, 25), however, without proper intervention, deterioration for older adults may occur and become exposed to many adverse health outcome and poor quality of life among older adults (26).

By taking the aforementioned facts into consideration, assessing the prevalence of frailty and its associated factors will help in building future plans to decrease the burden of frailty through implementing targeted interventions in early stages. Although numerous studies have been done on frailty in developed countries, frailty status among older adults in developing countries like Ethiopia is not known. Therefore, this study aims to determine the prevalence and associated factors of frailty among community-dwelling older adults living in Gondar town, Northwest Ethiopia.

Methods

Study design and setting 

A community based cross sectional study was conducted from April to June 2022. The study was conducted in Gondar town, Amhara regional state, Northwest Ethiopia. The city is located in central Gondar zone, Amhara regional state, 748 kilometers Northwest of Addis Ababa, Ethiopia capital, and about 180 kilometers from Bahir Dar, Amhara regional state's capital. Gondar is one of the ancient and largely populated cities in the country. It has an altitude of 12˚360N 37˚280E and a longitude of 12.60˚N 37.467˚E with an elevation of 2133 meters above sea level. Gondar town has 25 kebeles (the smallest administrative units in Ethiopia).According to the Gondar statistics agency's 2021/22 projection from 2007 population census data, the total population of Gondar town was estimated at 390,000 more than half of the population were women and 9870 were older adults (27).The town has one comprehensive specialized hospital and eight health centers they providing health services to the population. 

Population and sample size

The source population was all population of community dwelling older adults aged 60 years and above living in Gondar town. Older adults aged 60 years and above in selected kebeles (which is the smallest administrative unit in Ethiopia) during the study period were the study population. Older adults aged 60 years and above who were permanent residents (≥6 month) in the selected kebeles were included.Those whowere critically ill or mentally unstable to respond and those who did not give informed written consent were excluded.

Sample size determination

The sample size was determined using a single population proportions formula assuming, 50% anticipated prevalence of frailty, since there was no study conducted before in Ethiopia, a 95% confidence interval, and a 5% margin of error.

 n= sample size, Z_α/2 (1.96) = critical value at 95% confidence interval, p = expected estimates of prevalence value of frailty (50%), d = Margin of sampling error (5%).

                                     n =   Z (α/2)²p (1-p)                                                                             

                                                 d²

n= (1.96)²0.50.5/ (0.05)²    =3.84160.25/0.0025

                                                      n= 384.37385

By considering a design effect of 1.5 and 10% non-response rate multiplier, the minimum adequate final sample size was 636. But because of the effect of cluster sampling, a total of 670 older adults were interviewed from a total of 645 household.

Sampling technique and procedure

Gondar town has 25 kebeles. Eight kebeles were selected by lottery method. A single stage cluster sampling technique was used to select study participants. All eligible older adults in the selected cluster were interviewed in their household (figure 1).       

Methods of data collection and tools 

After obtained permission from ethical review committee from university of Gondar collage of medicine and health science house to house visit was done. Face-to-face interview was taken from study participants using a predesigned pretested structured schedule with the following domains.  

1. Socio-demographic characteristics;
2. Clinical related factors;
3. Tilburg frailty indicator part; 
4. Katz index of independency; 
5. Geriatric Depression Scale short form (GDS);
6. Life style related factors 

The other detailed contents of the questionnaire were developed from previous literature, and the questionnaire was modified based on all the variables that directly meet the objective of the study. It was prepared in an English version and translated to the Amharic language back to English to ensure consistency by language experts. The questionnaire had six parts. The first part of the questionnaire was focus on social-demographic factors, the second part on health-related factors, the third part on ADL dependency, the fourth part on depression, the fifth part on behavioral factors and six part measurement of frailty. Data collection was done by four trained health extension workers and two physiotherapist supervisors, and the data was collected by interviewing the participants using a structured questionnaire.

Tilburg frailty indicator part .It is a self‑reported schedule for assessment of frailty through its three important components, such as physical, psychological, and social. Eight questions regarding physical component, four questions on psychological component, and three questions on social component was asked. Respondents were  required to answer ‘yes’ or ‘no’ and the total attainable score is  ranged from 0 to 15.An individual with a score of ≥5 considered to be frail (64). 

Katz index of independency: is used to assess the functional status of older adults. The index ranks adequacy of performance in the six functions of (bathing, dressing, toileting, transferring, continence, and feeding).It’s interpretation of scored is given yes= 1/no=0 for independence in each of the six functions of items, and   a score of  6/6 indicates full function, a score of  4/6 indicates moderate impairment and if it’s score of   2/6 or less indicates severe functional impairment and the attainable score will be 0 to 6.An individual with score of ≤5 was taken as ADL dependence (58). 

The Geriatric Depression Scale short form (GDS): Was used to screen for depressive symptoms in this study. The 15 items in the GDS-SF were extracted from the original 30-item GDS. Respondents were required to answer ‘yes’ or ‘no’ to the 15 statements that describe either a positive or a negative emotion/condition. Attainable score ranges from 0 to 15 and an individual with a score of ≥5 considered to be depressed (59).

Operational definition

Frailty: In this study an older adult is considered as frail if the score of Tilburg frailty indicator is ≥5 (28). 

ADL dependency: Measured by Katz index of Independence in activities of daily Living an individual with score of ≤5 will be taken as ADL dependence (29).  

Depression: Measured by geriatric depression scale, short form (GDS), an individual with a score of ≥5 considered to be depressed (30).

Older adults: The age at which a person becomes 60 years and above refers to the older adults (21, 22, 31, 32).

Physical exercise: Is any kind of regular moderate/vigorous intensity exercise (such as walking, cycling, and sports) done at least 150 minutes per week (33).

Smoker: A smoker is a person who smokes cigarettes daily whatever the number of cigarettes (34).

Alcoholics: Alcoholic is a person who drinks beer, local beer or areke, tella, or tej every day or every other day (34).

Morbidity: is defined as having any type of illness or perceived health problem and/or informed by a physician ahead of data collection period (35).

Statistical analyses

The collected data was entered into Epidata and exported, coded and analysis was done using Statistical Package for the Social Sciences (SPSS) Version 26. First binary logistic regression was undertaken at p-value of 0.25 to identify potential candidates significantly associated with the outcome variable. Then variables were put together into multivariable logistic regression analyzes to identify the independent associated factors of    Frailty. Variables with a p value of < 0.05 at 95% confidence interval (CI) and their odds ratio (OR) were used to interpret the findings of the final model.

Results

A total of 607 older adults were included in this study making a response rate of 90%. Among the total respondents more than half of the study participants 312 (51.4%) were male and the median age of the study participants were 70, an inter-Quartile Range (IQR) 65-80 , age range from 60 to 95 years (See Table1).

Table 1: Socio-demographic characteristics of community dweller older adults living in Gondar town, Northwest, Ethiopia, 2022 (n = 607)

Clinical related characteristics

More than one third 219 (36.1%) of study participants had two or more comorbidities and 161 (26.5%) of study participants had a history of hospitalization in the past one year. Almost one third of study participants 208 (34.1%) were ADL dependent, and 406 (66.9%) were depressed (See Table2).

Table 2: clinical related characteristics of the study participant of community dweller older adults living in Gondar town, Northwest Ethiopia, 2022 (n=607)

Lifestyle related characteristics

From total participants, 223 (36.7%) of the study participants' were physically inactive. Regarding smoking status, 51 (8.4%) of the participants were smokers, and 142 (23.4%) were alcoholic (See table 3).

Table 3: lifestyle related characteristics of the study participant among community dweller older adults living in Gondar town, Northwest Ethiopia, 2022 (n=607).

  Prevalence of frailty

The overall prevalence of frailty in this study was found to be 39 % (CI 95%, 35.5-43.1). Among those who had developed frailty, the majority of study participants 136 (46.1%) were female and regarding age category, 125(75.3%) of them were aged 80 and older. Likewise, the majority of the study participants 51(56.0%) were primary or less educated, and nearly two thirds of the study participants 128 (64.3%) were unmarried/divorced/widowed are (shown table 4).

Table 4: Socio-demographic characteristic and frailty among community dweller older adults living in Gondar town, Northwest Ethiopia, 2022 (n=607).

The associated factors of frailty among older adults

In bivariate logistic regression variables such as sex, age, marital status, income status, morbidity, hospitalization, ADL dependency and depression were significantly associated with frailty. In multivariate logistic regression variables such as, age 80 and older (AOR=6.26 CI (3.41-11.48), having two or more morbidity (AOR=6.05 CI (3.51-10.43), ADL dependency (AOR=4.12 CI (2.49-6.80) and depression (AOR = 2.68 CI (1.55-4.63) were significantly associated with frailty are (shown in table 5).

Table 5: Bivariate and multivariable logistic regression analysis of associated factors among community dweller older adults living in Gondar town, Northwest Ethiopia 2022 (n=607).

 Note 1=Reference category, CI= confidence interval * statistically significant at P<0.05.

Discussion

The aim of this study was to assess the prevalence and associated factors of frailty among community dweller older adults living in Gondar town. The overall prevalence of frailty among older adults living in Gondar town in this study was 39 %( CI 95%, 35.5-43.1).This finding indicates that frailty is a high public health burden and health problem among community dweller older adults living in Gondar town. The results of the present study revealed that frailty among older adults is significantly associated with age 80 and older, having two or more morbidity, being ADL dependent and depression.    

The prevalence of frailty in our study (39%) was in line with a study conducted in West India (38.8%) (36) and Netherlands (40.2%) (37).This might be due to similar study methodology and measuring tool (TFI) used.

However, it was lower compared with studies conducted in Cuba (51%) (38) and south India (63%) (21).This discrepancy might be due to difference in methodology and better health access in the study area. In addition, unlike our study, where study participants were recruited from the general public, study participants in Cuba were recruited from a geriatric medical facility. This is supported by additional Studies showing that residents of medical care facilities had a higher prevalence of frailty than people living in the general population (9, 39). Similarly, the study population in south India was made up primarily of rural dwellers which might be the cause of the disparity between our study and the study conducted there. Older people in rural areas are said to have lower incomes, lower levels of education, and less access to health care and insurance, all of which contribute to poorer health (40).

Our study reported higher prevalence of frailty compared with study done in USA (9.1%) (41), Saudi Arabia (21.4%) (31) and China (9.9%) (40).This difference might be due to the method of identifying frailty tool, socioeconomic status, and health service variation of the study participants. In addition, unlike our study, Fried's frailty criteria (4), which assess primarily the physical aspect of the research participants, were used to measure frailty in the studies conducted in the United States, Saudi Arabia and China. However, in the current investigation, frailty was evaluated using multidimensional methods that took the study participants' physical, psychological, and social dimensions into account. Another argument could be elderly individuals living in high-income countries have different socioeconomic statuses, are more conscious of healthy living, are financially secure, and have access to superior healthcare (42).

According to this study, participants 80 years of age and older were 6.26 times more likely to experience frailty than those between the ages of 60 and 69. This study's findings were consistent with research from South India, Colombia, Saudi Arabia, and Indonesia that found significant association between frailty and age 80 and beyond (21, 31, 32, 43). The interactions between particular systems that raise the risk of frailty, like inflammation and endocrine dysregulation, and physiologic changes associated with advancing age may be the cause of this (44). In addition, physiologic changes in old age may lead to sarcopenia and a higher risk of frailty (45).

The results of this study also showed that people who had two or more comorbidities were 6.05 times more likely to develop frailty than those who did not. Similar to this, our study's findings were supported by studies from Brazil, Spain, Singapore, and the United States, that revealed a substantial relationship between frailty and comorbidity (41, 46-48). The accumulating effects of medical conditions and other deficiencies in old age may be the cause of unfavorable health outcomes like reduced quality of life, disability, prolonged hospital admissions, complex pharmaceutical regimens, and susceptibility to frailty (49, 50).

 This study showed that persons with ADL dependence were 4.12 times more likely to acquire frailty than participants without ADL dependence. Our study's findings, which were also corroborated by research from the USA, Brazil, and West India, showed that the presence of ADL dependence in older persons was strongly associated with frailty (36, 41, 51). This could be because older persons with ADL dependence engage in less physical exercise, which raises their risk of frailty (45).

Furthermore, this study found that persons with depression were 2.68 times more likely to become feeble than participants without depression to experience frailty. According to this study's findings, depression in older adults was the highest risk factor for frailty, which is consistent with research from China and Iran (23, 40). Given that depressed people frequently lose weight, become inactive, and subsequently lose muscle mass, strength, and tolerance to exercise, factors leading to an increase in cytokines which is closely linked to the onset of frailty and could be the hypothesis that depressive symptoms trigger frailty from a biological point of view (45). The findings of our study are unlikely to be transferable to other contexts because we only enrolled older persons who resided in metropolitan communities. Because of the cross-sectional design, the cause of frailty cannot be proven. Despite these drawbacks, it is a groundbreaking study that fills a significant evidence vacuum about frailty in Ethiopia, particular in the study area.

Conclusion

The prevalence of frailty was found to be remarkable (39%), and we conclude that frailty should be recognized as a priority public health problem among older adults in the study area. Being 80 years old and above, having two or more morbidity, activity of daily life dependency and depression were associated factors for frailty. Therefore, it is important to focus on educating the older adult population about healthy aging and orienting them on these modifiable risk factors should be considered to mitigate the problem.

Abbreviations

ADL-Activity of Daily Living, AGS-American Geriatrics Society, AOD-Adjusted Odd Ratio, BGS-British Geriatrics Society, CDC-Communicable Disease Control, CGA- Compressive, Geriatrics Society, CI-Confidence Interval, COR-Crude Odd Ratio, FI-Frailty Index, GFI-Groningen Frailty Index (GFI),QOF-Quality of Life, SPSS- Statistical Package for Social Software, TFI-Tilburg Frailty Indicators, USA-United State of America, WHO -World Health Organization.

Declarations

Competing interests

The authors declare that they have no competing interest.

Authors' contributions

MDT involved from conception of the topic, coordinated the data collection activity, analyzed the data, drafted and approved the manuscript. KS, KG, DI, GJ, MG, YA and AKK revised the proposal and participated in the data collection, analysis and manuscript writing. Finally, all authors read and approved the final manuscript.

Acknowledgements

We are grateful to the University of Gondar, College of Medicine and Health Science for funding to undertake this research project. We would also like to acknowledge the sub-cities and selected kebele bureaus for their willingness and support during data collection, study participants and data collectors for their participation and time.

Ethics approval and consent to participate

Ethical clearance was obtained from the Health Research Ethics Review Committee University of Gondar College of medicine and health Sciences in accordance with Helenski declaration.  Written informed consent was obtained from each of the study participants after being informed in detail about the objective, purpose, benefit, risk, and the confidentiality of information and the voluntary nature of participation. 

Consent for publish

Not applicable 

Availability of data and material

Since this is a funded work, the raw data is property of university of Gondar. Data request can be arranged by the investigators for a reasonable formal request.

Funding

This work was fully funded by university of Gondar. The funder has no role in the design of the study, data collection, and analysis, interpretation of data and in writing the manuscript. 

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