Epidemiology of frailty and associated factors among older adults living in rural communities in Taiwan

Journal Pre-proof Epidemiology of Frailty and Associated Factors among Older Adults Living in Rural Communities in Taiwan Chung-Yu Huang, Wei-Ju Lee, Hui-Ping Lin, Ren-Chou Chen, Chi-Hung Lin, Li-Ning Peng, Liang-Kung Chen

PII:

S0167-4943(19)30229-8

DOI:

https://doi.org/10.1016/j.archger.2019.103986

Reference:

AGG 103986

To appear in:

Archives of Gerontology and Geriatrics

Received Date:

22 August 2019

Revised Date:

17 November 2019

Accepted Date:

17 November 2019

Please cite this article as: Huang C-Yu, Lee W-Ju, Lin H-Ping, Chen R-Chou, Lin C-Hung, Peng L-Ning, Chen L-Kung, Epidemiology of Frailty and Associated Factors among Older Adults Living in Rural Communities in Taiwan, Archives of Gerontology and Geriatrics (2019), doi: https://doi.org/10.1016/j.archger.2019.103986

This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier.

Epidemiology of Frailty and Associated Factors among Older Adults Living in Rural Communities in Taiwan 1,3,4

Chung-Yu Huang, 2,3,4Wei-Ju Lee, 5Hui-Ping Lin, 5Ren-Chou Chen, 5Chi-Hung Lin. 1,3,4,*Li-Ning

Peng, 1,3,4Liang-Kung Chen 1

Center for Geriatrics and Gerontology, Taipei Veterans General Hospital, Taipei, Taiwan;

2

Department of Family Medicine, Taipei Veterans General Hospital Yuanshan Branch, Yi-Lan,

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Taiwan; 3Aging and Health Research Center, National Yang Ming University; 4Department of Geriatric Medicine, National Yang Ming University School of Medicine; and 5Department of Health,

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New Taipei City Government, New Taipei City, Taiwan

Corresponding author:

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Dr. Li-Ning Peng

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Center for Geriatrics and Gerontology, Taipei Veterans General Hospital No. 201, Sec 2, Shi-Pai Road, Beitou District, Taipei, Taiwan 11217

TEL: +886-2-28757830

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Email: [email protected]

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FAX: +886-2-28757711

HIGHLIGHTS 1. The prevalence of frailty in rural communities is higher. 2. Socio-economic status and access to healthcare services may be the key 3. Better education, cognitive performance, instrumental activities of daily living are protective against frailty 4. Depressive symptoms, impaired timed up-and-go test, urinary incontinence and risk of

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malnutrition are associated factors for frailty

Abstract Frailty is a well-known geriatric syndrome with strong adverse health impact to older people. The socio-economic status and the accessibility of health services in rural communities may increase the risk of frailty.

We conducted a cross-sectional study in rural districts of New Taipei

City, Taiwan, to explore the epidemiology and associated factors of frailty. Data of 1,014 participants (mean age: 78.7 ± 8.0 years, 66.3% females) were obtained with the prevalence of frailty and pre-frailty 17.6% and 23.1%, respectively.

The mean Barthel Index was 98.5 ± 5.8, and Frail older people tended

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their mean Instrumental Activities of Daily Living (IADL) were 7.2 ± 1.5.

perform worse in timed up-and-go tests (24.7% in frailty and 0.4% in robust). The mean minimental state examination (MMSE) score for all participants was 23.3 ± 5.1, but was lower in frail Depressive symptoms were more common in frail older persons than

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older for around 5 points.

robust ones (31.5% vs 14.3%), which was similar in the nutritional status.

Results of the logistic

The presence of depressive symptoms, urinary incontinence, abnormal performance of

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frailty.

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regression showed that better education, IADL and MMSE scores were protective factors against

TUG, and the presence of the risk for malnutrition were all independent assciated factors for

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frailty. In conclusion, the prevalence of frailty was higher among older adults living in rural communities that deserves specific public health attentions. Further intervention study covering

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special needs in rural communities is needed to promote health of older people.

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Key Words: Frailty, elderly, sarcopenia, geriatric syndrome, rural health

Introduction Aging is a global phenomenon that poses various challenges to all countries, and Taiwan is no exception [1-3]. As one of the fastest aging countries in the world, Taiwan has become the aged society and is expected to become a super-aged society in 2026 [1]. With the rapid growth of older population, the impacts of multimorbidity, functional declines, disability, dementia and the combinations of these conditions have become unique challenges to the world.

Previous studies

have demonstrated that disability is of greater prognostic significance than multimorbidity among

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older adults [4], which highlights the unique care needs for older people. In the development of disability, frailty has been widely accepted to be the intermediate state between healthy and

disability, and its potential reversibility also become the major focus for disability prevention.

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Frailty has been shown to result in various adverse health outcomes, including increased risk for hospitalizations, disability, nursing home admissions, and mortality [5-7].

Reduced physiologic

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reserve and increased the vulnerability to adverse outcomes were the key features of frailty [8].

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A number of risk factors of frailty have been reported before that involves disease factors, functional factors, nutritional factors, social factors and many others. Our previous study have

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shown the urbanization substantially influenced the epidemiology and associated factors of frailty, and the clinical impact of frailty may be higher in rural areas than in urban communities [9-11].

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To define frailty is a great challenge because of its complex pathophysiology that interacts with environmental and social factors [8]. Currently, two major approaches are commonly

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accepted to define frailty, i.e. phenotypic approach of physical frailty [12], and the frailty index defined based on the theory of cumulative deficits [13]. Although both methods may effectively identify frail older adults in the communities, the socio-demographic characteristics may significantly differ between them [14]. However defined, many studies identified risk factors and design intervention programs based on those discoveries [15-18]. Among all reported risk factors, older age, low education level, and poor socio-economic status were all significant risk

factors in frailty development [19,20].

These risk factors may also be highly associated with

urbanization status of the investigated communities. In rural communities, frailty is more commonly to be associated with poorer self-related health, higher prevalence of depressive symptoms, and poorer sleep quality [21]. However, a recent meta-analysis showed that the prevalence of frailty was lower in rural areas, but the urban-rural difference disappeared after adjustment of potential confounding factors [10].

Due to the potential differences in socio-

demographic and health characteristics of frailty in rural communities, this study aimed to explore

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the epidemiology and associated factors of frailty among older adults living in rural communities in Taiwan, and to implement effective case-finding processes and intervention programs based on

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the differences in urbanization status.

Methods

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Study design and participants

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This was a cross-sectional study supported by the Department of Health of New Taipei City Government that aimed to investigate the prevalence and associated factors of frailty among

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seniors living in rural townships (Rui-Fang, Ping-Xi, Shuang-Xi, and Gong-Liao). All residents aged 65 years and older living in these communities were invited for study via the assistance provided

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by the local public health centers. The whole study was supported by the Department of Health, New Taipei City Government and data were obtained under authorization. Therefore, the the

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approval of institutional review board is waived. Demographic characteristics and functional assessment All participants were assessed by trained staff, and data including demographic characteristics, anthropometric measurements, past medical history, and lifestyle behaviors were collected. Besides, the functional assessment was performed for each participants, including physical function, cognitive function, psychological condition, nutritional status, frailty status and

others. The functional assessment was performed by well-trained research staff. Among all functional domains, physical function was evaluated by Barthel Index [22], cognitive function assessed by the Chinese version of Mini-Mental Status Examination (MMSE) ]2324], depressive symptoms assessed by the Geriatric Depression Scale-5 items (GDS-5) [25], and nutritional status assessed by the Mini-Nutritional Assessment-Short Form (MNA-SF) [26].

Besides, all participants

performed timed up-and-go (TUG) test that evaluated the risk of falls and 20 seconds were determined as the cut-off for TUG performance [27].

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Definition of frailty Frailty was defined using modified criteria from Cardiovascular Health Study, which contained 5 components, i.e. weight loss, exhaustion, weakness, slowness, and low physical activity [12].

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Subjects who were positive for three or more components were defined as frailty, those with 1 or 2 component(s) were defined as pre-frailty, and without any component was considered robust.

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In this study, weight loss was defined as unintentional weight loss for 5 kilograms in the past year,

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and exhaustion was defined based on self-reported results from the Center for Epidemiology Studies Depression Scale. Weakness was defined as low handgrip strength by using the proposed

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cutoff by the consensus report of the Asian Working Group for Sarcopenia [28], whereas slowness was defined as walking speed less than 0.8 meters per second.

Physical activity was assessed by

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the International Physical Activity Questionnaire (IPAQ) [29], and low physical activity was defined as those with weekly average Metabolic Equivalent of Task (MET)-hour less than 2.5 in women or

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3.75 in men.

Statistical analysis

In this study, categorical variables were presented as number (percentage), and continuous variables were presented in mean ± standard deviation (SD). In the comparative analysis, Chisquare analysis was used in categorical variables, and Analysis of variance (ANOVA) was used for continuous variables. Logistic regression was used to identify independent associated factors for

frailty that all variables with P<0.10 in univariate analysis were entered in the regression model. All statistical analysis was done by the commercial software (SPSS 24.0, IBM Corp, Chicago, IL, USA) and a two-tailed P value<0.05 was considered as statistically significant.

Results Demographic characteristics Overall, a total of 1,126 participants were enrolled for study and 112 participants were

characteristics and past medical history.

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excluded for further analysis due to data incompleteness. Table 1 summarized demographic The mean age of the remaining 1,014 participants was

78.7 ± 8.0 years, and 672 (66.3%) of them were women. The overall prevalence of frailty in this

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study was 17.6%, and 23.1% of all participants were robust that leaves 49.3% of all participants were pre-frail. The mean body mass index (BMI) of all participants was 25.5 ± 3.6 lg/m2, and frail

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older people were having lower BMI than others (Table 2).

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Most of the participants have received basic education only, and nearly a half of them were considered as illiterate (Table 1), especially those with frailty (Table 2).

Over a half of participants

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(55.8%) remained married, but frail older people tended to live without spouse (Table 2). About one-fifth of all participants lived alone (21.8%), and 25.6% lived with their spouse.

In general,

than others.

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over a half (57.9%) of participants live independently, but frail older people were more dependent In this study, 51.1% of all participants had hypertension; 22.9% of all participants

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had diabetes mellitus, and 23.6% had heart diseases. Insomnia was reported among 24.6% of all participants, and only 2.4% of had been diagnosed having depressive disorder.

Among all past

medical history, frail older people were more likely to have stroke, malignancy and insomnia (Table 2). Functional assessment

Since almost all participants reported independent living and the mean Barthel Index was 98.5 ± 5.8, and their mean level of Instrumental Activities of Daily Living (IADL) were 7.2 ± 1.5. Participants with frailty were having lower Barthel Index and IADL (Table 2).

In terms of sensory

impairment, 17.5% of all participants had visual impairment, which was higher (23.6%) in frail older people. On the other hand, 5.7% of all participants reported hearing impairment, and frail participants were significantly more likely to be hearing impaired 12.9% (Table 2).

The

prevalence of abnormal TUG test was 7.1%, but 17.9% of participants reported history of falls in

TUG tests (24.7% in frailty and 0.4% in robust) (Table 2).

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the previous year. Moreover, frail older people tended to have higher prevalence of abnormal

The mean MMSE score for all participants was 23.3 ± 5.1, but frail older people were of

The prevalence of depressive

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significantly lower mean MMSE score for around 5 points (Table 2).

symptoms was 14.3%, which was also significantly higher in frail older people (31.5%).

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were of risk of malnutrition (Table 2).

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Moreover, 10.3% of all participants were at risk for malnutrition and 24.7% of frail older people

Independent associated factors for frailty

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Results of the logistic regression showed that higher education level, better performance in IADL and higher MMSE scores were protective factors against frailty. On the other hand, the

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presence of depressive symptoms, urinary incontinence, abnormal performance of TUG, and the

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presence of the risk for malnutrition were all independent associated factors for frailty (Table 3)

Discussion

In this study, the prevalence of frailty, pre-frailty and robust was 17.6%, 59.4%, and 23.1%, respectively. Compared to a previous study in all districts of New Taipei City [4], frailty was more common among the study participants, which may be explained by the follows: (1) lower socioeconomic status among residents living in rural communities may increase the prevalence of

frailty, (2) lifestyles of older adults in these rural communities may contribute to the higher prevalence of frailty, and (3) limited access to health promotion activities in rural communities. Our previous study has confirmed that older adults living in rural areas have higher chances of having frailty, disability, multimorbidity, especially mental illnesses [4].

The higher prevalence of

frailty in the rural communities in this study may be multifactorial, which may not be simply explained by the rurality. However, the previous study used the data of annual health examinations that the majority of older adults may participate, even among older adults with

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disability, dementia, and other chronic conditions [4]. In this study, participants were invited by the staff of the local community health centers, so demographic characteristics of participants differ greatly from the previous study.

The high prevalence of frailty and pre-frailty may suggest

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higher risk of developing subsequent disability. In particular, the functional status of these study participants was high, suggesting that they were free from existing disability.

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In this study, better education levels, higher MMSE score and better IADL were all protective

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factors against frailty, but depressive symptoms, urinary incontinence, risk of malnutrition and abnormal performance for TUG test were independent associated factors for frailty. TUG tests

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have been shown to predict falls [31,32], therefore, frail older adults were of greater risk of falls that deserve further fall prevention intervention. Indicated by Fried, et al., frailty is not disability,

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but represents a vulnerable state due to reduced physiological reserve and higher susceptibility to adverse events [30]. Similar to previous studies, frailty is a complex geriatric syndrome with

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multiple comorbid conditions [8], which represents special care needs [33]. Moreover, frailty is considered as a reversible state and a multi-modal intervention program is generally recommended with favorable clinical efficacy [34-36].

Lower socio-economic status in rural

communities, featured by lower education levels, may increase the risk of older adults for frailty. Meanwhile, the limited access for healthcare services and health promotion activities in rural communities may also contribute the higher risk of frailty. These findings highlight the needs for

a comprehensive approach to tackle the potential disability risk of frailty. Moreover, frail older adults were of lower MMSE score that may suggest the risk of further cognitive impairment in the late life. Mental health, i.e. depressive symptoms and cognitive impairment, should also be included in the frailty intervention programs [4].

Older adults with concomitant functional

declines in physical and cognitive domains were of greater risk for disability, dementia and even mortality [37-40]. Despite all the efforts went into this study, there are several limitations.

First, this study

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enrolled participants from four major rural communities in New Taipei City that may not be representative enough for all rural areas in Taiwan. However, rural communities usually share some common characteristics, so results of this study are still of great importance. Second, this

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study only enrolled participants who were willing to participate in the study and the clinical characteristics of non-participants remained unclear. Third, from the demographic

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underestimate the clinical impact of frailty.

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characteristics, study participants were relatively healthier with intact physical function that may

In conclusion, the prevalence of frailty was higher among older adults living in rural

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communities that higher education level, better MMSE score, and better IADL status were protective against frailty. On the other hand, abnormal performance of TUG, depressive

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symptoms, urinary incontinence and risk of malnutrition were all independent associated factors for frailty. Further study is needed to develop appropriate intervention programs and to

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evaluate the clinical efficacy for frailty and the potential benefits for disability prevention.

Conflicts of Interest All authors declare no conflicts of interest

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41. TABLE 1. DEMOGRAPHIC CHARACTERISTICS OF STUDY PARTICIPANTS Female (n = 672) 78.8 ± 7.9

Height (cm)

153.4 ± 8.1

149.7 ± 6.1

160.5 ± 6.8

< 0.001 ***

Weight (kg)

59.9 ± 9.8

57.7 ± 8.9

64.3 ± 10.2

< 0.001 ***

Body mass index (BMI) (kg/m2)

25.5 ± 3.6

25.7 ± 3.7

24.9 ± 3.5

0.001 **

12 (1.8%)

125 (36.6%)

< 0.001 ***

79 (23.1%)

< 0.001 ***

Current alcohol drinking

101 (10.0%)

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137 (13.5%)

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Current smoking

Pr

Education level Illiteracy ≤ 6 years

Marital status With spouse Living arrangement

0.809

81 (24.0%)

431 (42.8%)

260 (38.9%)

171 (50.6%)

131 (13.0%)

45 (6.7%)

86 (25.4%) < 0.001 ***

285 (42.4%)

280 (82.1%) < 0.001 ***

219 (21.8%)

179 (26.9%)

40 (11.8%)

Living with spouse

258 (25.6%)

129 (19.4%)

129 (37.9%)

Living with relatives or friends

529 (52.6%)

358 (53.8%)

171 (50.3%)

Hypertension

518 (51.1%)

354 (52.7%)

164 (48.0%)

0.155

Diabetes mellitus

232 (22.9%)

162 (24.1%)

70 (20.5%)

0.192

Heart diseases

239 (23.6%)

173 (25.7%)

66 (19.3%)

0.022 *

36 (3.6%)

18 (2.7%)

18 (5.3%)

0.035 *

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Living alone

364 (54.4%)

565 (55.8%)

P-value

< 0.001 ***

445 (44.2%)

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> 6 years

22 (3.3%)

Male (n = 342) 78.6 ± 8.3

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Age (years)

Total (n=1,014) 78.7 ± 8.0

Medical history

Stroke

50 (4.9%)

16 (2.4%)

34 (9.9%)

< 0.001 ***

Renal insufficiency

73 (7.2%)

34 (5.1%)

39 (11.4%)

< 0.001 ***

Malignancy

24 (2.4%)

15 (2.2%)

9 (2.6%)

0.692

Depressive disorder

24 (2.4%)

15 (2.2%)

9 (2.6%)

0.692

249 (24.6%)

173 (25.7%)

76 (22.2%)

0.218

Physical frailty status

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pr

Insomnia

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Lung Disease

234 (23.1%)

Pre-Frail

602 (59.4%)

406 (60.4%)

196 (57.3%)

Frailty

178 (17.6%)

123 (18.3%)

55 (16.1%)

98.5 ± 5.8

98.7 ± 4.2

98.1 ± 7.9

0.204

7.2 ± 1.5

7.4 ± 1.4

6.7 ± 1.7

< 0.001 ***

23.3 ± 5.1

22.6 ± 5.2

24.8 ± 4.4

< 0.001 ***

Depressive symptoms (GDS-5 ≥ 2)

145 (14.3%)

99 (14.7%)

46 (13.5%)

0.581

Polypharmacy

152 (15.0%)

84 (12.5%)

68 (19.9%)

0.002 **

177 (17.5%)

117 (17.4%)

60 (17.5%)

0.958

Auditory impairment

58 (5.7%)

30 (4.5%)

28 (8.2%)

0.016 *

Timed up-and-go test > 20 sec

71 (7.1%)

44 (6.6%)

27 (8.0%)

0.42

Urinary incontinence

75 (7.4%)

50 (7.4%)

25 (7.3%)

0.94

104 (10.3%)

63 (9.4%)

41 (12.0%)

0.195

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Robust

Pr

Functional assessment Barthel index

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Visual impairment

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IADL MMSE

143 (21.3%)

0.15

Risk of malnutrition (MNA-SF ≤ 11)

91 (26.6%)

* P-value < 0.05; ** P-value < 0.01; *** P-value < 0.001 MMSE: Mini-Mental Status Examination; GDS: Geriatric Depression Scale; IADL: Instrumental Activity of Daily Living; MNA-SF: Mini Nutrition Assessment-Short Form; Polypharmacy: defined as taking more than 4 medications

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Frailty (n=178) 81.3 ± 7.9 69.1% 151.1 ± 8.1 56.6 ± 9.4 24.8 ± 3.7 25 (14.0%) 10 (5.6%)

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TABLE 2. COMPARISONS BETWEEN PARTICIPANTS WITH DIFFERENT RAILTY STATUS Robust Pre-frailty (n=234) (n=602) Age (year) 76.0 ± 7.0 79.0 ± 8.1 Sex (Women%) 61.1% 67.4% Height (cm) 156.1 ± 8.0 153.0 ± 7.9 Weight (kg) 61.9 ± 8.3 60.2 ± 10.2 Body mass index (kg/m2) 25.4 ± 3.0 25.7 ± 3.8 Current smoking 31 (13.3%) 81 (13.5%) Current alcohol drinking 30 (12.8%) 61 (10.1%) Education level Illiteracy 75 (32.3%) 273 (45.6%) ≤ 6 years 102 (44.0%) 255 (42.6%) > 6 years 55 (23.7%) 71 (11.9%) Marital status With spouse 156 (67.0%) 321 (53.3%) Living arrangement Living alone 47 (20.4%) 133 (22.2%) Living with spouse 62 (27.0%) 153 (25.6%) Living with relatives or friends 121 (52.6%) 312 (52.2%) Medical history Hypertension 115 (49.1%) 313 (52.0%) Diabetes mellitus 43 (18.4%) 143 (23.8%) Heart diseases 47 (20.1%) 144 (23.9%) Stroke 6 (2.6%) 14 (2.3%) Lung Disease 13 (5.6%) 27 (4.5%) Renal insufficiency 12 (5.1%) 52 (8.6%) Malignancy 11 (4.7%) 8 (1.3%) Depression disorder 5 (2.1%) 15 (2.5%) Insomnia 51 (21.8%) 139 (23.1%) Functional assessment

P-value < 0.001*** 0.15 < 0.001*** < 0.001*** 0.011* 0.937 0.067 < 0.001***

97 (55.1%) 74 (42.0%) 5 (2.8%) < 0.001 88 (49.4%) 0.958 39 (21.9%) 43 (24.2%) 96 (53.9%) 90 (50.6%) 46 (25.8%) 48 (27.0%) 16 (9.0%) 10 (5.6%) 9 (5.1%) 5 (2.8%) 4 (2.2%) 59 (33.1%)

0.752 0.147 0.252 < 0.001*** 0.730 0.101 0.014* 0.949 0.013*

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Barthel index 99.4 ± 2.0 98.9 ± 3.8 95.9 ± 11.3 < 0.001*** IADL 7.5 ± 0.9 7.2 ± 1.5 6.4 ± 2.0 < 0.001*** MMSE 25.8 ± 3.7 23.2 ± 4.9 20.5 ± 5.7 < 0.001*** Depressive symptoms (GDS-5 ≥ 2) 9 (3.8%) 80 (13.3%) 56 (31.5%) < 0.001*** Polypharmacy 23 (9.8%) 88 (14.6%) 41 (23.0%) 0.001** Visual impairment 31 (13.2%) 104 (17.3%) 42 (23.6%) 0.023* Auditory impairment 6 (2.6%) 29 (4.8%) 23 (12.9%) < 0.001*** Timed up-and-go > 20 sec 1 (0.4%) 27 (4.5%) 43 (24.7%) < 0.001*** Urinary incontinence 12 (5.1%) 36 (6.0%) 27 (15.2%) < 0.001*** Risk of malnutrition (MNA-SF ≤ 11) 4 (1.7%) 56 (9.3%) 44 (24.7%) < 0.001*** * P-value < 0.05; ** P-value < 0.01; *** P-value < 0.001; MMSE: Mini-Mental Status Examination; GDS: Geriatric Depression Scale; IADL: Instrumental Activity of Daily Living; MNA-SF: Mini Nutrition Assessment-Short Form; Polypharmacy: defined as taking more than 4 medications

TABLE 3. INDEPNENDT ASSOCIATED FACTORS FOR FRAILTY AMONG OLDER ADULTS LIVING IN RURAL COMMUNITIES IN TAIWAN 95% Confidence interval

Education level (> 6 years)

0.349

0.125 ~ 0.974

0.044 *

IADL

0.951

0.851 ~ 1.107

0.037 *

MMSE

0.937

0.896 ~ 0.980

0.004 **

Depressive symptoms (GDS-5 ≥ 2)

2.29

1.414 ~ 3.709

0.004 **

Timed up-and-go test > 20 sec

4.27

2.277 ~ 8.008

< 0.001 ***

Urinary incontinence

1.951

1.042 ~ 3.654

0.037 *

Risk of malnutrition (MNA-SF ≤ 11)

1.924

1.067 ~ 3.468

0.030 *

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Odds ratio

P value

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* P-value < 0.05; ** P-value < 0.01; *** P-value < 0.001; MMSE: Mini-Mental Status Examination; GDS: Geriatric Depression Scale; IADL: Instrumental Activity of Daily Living; MNA-SF: Mini Nutrition Assessment-Short Form