H.J. Coelho-Junior1,2, E. Marzetti2,3, A. Picca3, R. Calvani3, M. Cesari4,5, M.C. Uchida1
1. Applied Kinesiology Laboratory–LCA, School of Physical Education, University of Campinas, Campinas, SP, Brazil; 2. Università Cattolica del Sacro Cuore, Institute of Internal Medicine and Geriatrics, Rome, Italy; 3. Center for Geriatric Medicine (Ce.M.I.), Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, Rome, Italy; 4. Department of Clinical Sciences and Community Health, Università di Milano, Milan, Italy; 5. Geriatric Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy.
Corresponding author: Hélio J. Coelho-Junior, Department of Geriatrics, Neuroscience and Orthopedics, Fondazione Policlinico Universitario «Agostino Gemelli» IRCCS, Università Cattolica del Sacro Cuore. L.go F. Vito 1, Rome 00168, Italy. Tel.: +39 (06) 3015-5559. Fax: +39 (06) 3051-911, E-mail: firstname.lastname@example.org
J Frailty Aging 2020;9(4)197-213
Published online April 29, 2020, http://dx.doi.org/10.14283/jfa.2020.22
Objectives: The present study aimed at investigating the prevalence of prefrailty and frailty in South American older adults according to the setting and region. Design: A literature search combining the terms “frailty”, “South America” or a specific country name was performed on PubMed, EMBASE, Lilacs, and Scielo to retrieve articles published in English, Portuguese or Spanish on or before August 2019. Participants: Older adults aged 60+ years from any setting classified as frail according to a validated scale were included in the study. Measurements: Frailty assessment by a validated scale. Results: One-hundred eighteen reports (98 performed from Brazil, seven from Chile, five from Peru, four from Colombia, two from Ecuador, one from Argentina, and one from Venezuela) were included in the study. The mean prevalence of prefrailty in South America was 46.8% (50.7% in older in-patients, 47.6% in the community, and 29.8% in nursing-home residents). The mean prevalence of frailty in South America was 21.7% (55.8% in nursing-home residents, 39.1% in hospitalized older adults, and 23.0% in the community). Conclusions: Prefrailty and frailty are highly prevalent in South American older adults, with rates higher than those reported in Europe and Asia. In the community, almost one-in-two is prefrail and one-in-five is frail, while hospitalized persons and nursing-home residents are more frequently affected. These findings indicate the need for immediate attention to avoid frailty progression toward negative health outcomes. Our findings also highlight the need for specific guidelines for the management of frailty in South America.
Key words: Latin America, low-income countries, elderly, sarcopenia, mobility, nursing-home.
Frailty is a potentially reversible state of increased vulnerability to stressful events (1) that occurs as a result of multisystem biological derangements (2–5) and socioeconomic inequalities (6–8). Frailty progression increases the risk of several negative health-related outcomes, including disability, loss of independence, institutionalization, and death (9–11). Noticeably, frailty is associated with greater healthcare utilization and costs (12), making this condition a top public health priority (1).
Since the operationalization of the frailty phenotype by Fried et al. (13), considerable research has been devoted to explore its incidence (14), prevalence (15–18), associated factors (19, 20), and main outcomes (21). These efforts have allowed generation of recommendations and guidelines for the identification and management of frailty across healthcare settings (22–24). Yet, the majority of studies upon which guidelines are based were conducted in high-income countries, while very few publications have been produced in South America (14–16). Hence, epidemiological characteristics of frailty in this region are poorly described. This is especially concerning since South America, in spite of the image of a «young» region, is aging at a faster pace than Europe (25). Furthermore, risk factors for frailty development, such as socioeconomic disadvantages, chronic diseases and disabilities, are highly prevalent in South America (6).
To increase the knowledge of the epidemiology of frailty in South America, the present systematic review explored the prevalence of prefrailty and frailty in South American older adults according to settings, regions, and frailty assessment tools.
We conducted a systematic review of observational studies to investigate the prevalence of prefrailty and frailty in South America. The study was fully performed by investigators and no librarian was part of the team. This study complies with the criteria of the Primary Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) Statement (supplementary material 1) (26). All data are available in the Open Science Framework at https://doi.org/10.17605/OSF.IO/XZ2S8.
The following criteria were used for inclusion: (a) observational studies, including cross-sectional, cohort, case-control and longitudinal studies, which described or supplied data to calculate the prevalence of prefrailty and/or frailty in older adults from any setting (e.g., community, institutions); (b) age 60 years or more; (c) frailty assessment by a validated scale; and (d) published studies (English, Portuguese, and Spanish languages). There was no restriction on sample size or study population, and studies that investigated disease-specific populations were also included and analyzed accordingly. Studies that did not report the prevalence of robust older adults in addition to frailty prevalence or that classified participants as frail only according to reduced physical/or cognitive function were excluded.
Search strategy and selection criteria
Studies published on or before August 2019 were retrieved from the following four electronic databases by one investigator: (1) PubMed, (2) EMBASE, (3) Lilacs, and (4) Scielo. Reference lists for reviews and retrieved articles for additional studies were checked and citation searches on key articles were performed on Google Scholar and ResearchGate for additional reports. A search strategy was designed using keywords, MeSH terms, and free text words such as frailty, South America, Latin America, and the name of all South American countries. Keywords and MeSH terms (for PubMed), or its corresponding in Lilacs and Scielo (i.e., DeCS) were combined using Boolean operators. The complete search strategy used for the PubMed is shown in supplementary material 2. Only eligible full-texts in English, Portuguese or Spanish languages were considered for review.
Data extraction and quality assessment
Titles and abstracts of retrieved articles were screened for eligibility by two researchers. If an abstract did not provide enough information for evaluation, the full-text was retrieved. Disagreements were solved by a third reviewer. Reviewers were not blinded to authors, institutions, or manuscript journals. Data extraction was independently performed by two reviewers using a standardized coding form. Disagreements were solved by a third reviewer. Coded variables included methodological quality and the characteristics of studies. If two or more studies shared the same sample, the largest sample size was considered in the analysis (15, 18). The prevalence of prefrail and frailty were calculated according to the cutoff values used in the studies (supplementary material 3), so that no changes were performed when frailty identification was made using the Fried frailty phenotype (13), Tilburg frailty indicator (TFI) (27), Fatigue, Resistance, Ambulation, Illnesses, & Loss of Weight (FRAIL) scale (28), Kihon checklist (KCL) (29), and Study of Osteoporotic Fracture (SOF) (30) instruments. When participants were identified as visible vulnerable with the Edmonton frailty scale (EFS) (31) and apparently vulnerable with the Clinical Frailty Scale (CFS) (32), they were considered prefrail, as well as they were considered frail when were identified as Mild, Moderate, and Severe Frailty using the Edmonton frailty scale (CFS) (31) and mildly, moderate, and severely frail using the CFS (32).The quality of reporting for each study was assessed by two researchers using the Newcastle Ottawa Quality Assessment Scale (NOS) for non-randomized studies (33, 34). The agreement rate between reviewers for quality assessment was κ=0.93.
Of 20,229 records recovered from electronic databases and hand search, 19,612 were excluded based on duplicate data, title or abstract. Six-hundred seventeen records were fully reviewed and assessed for eligibility. Eventually, 118 studies met inclusion criteria (Figure 1).
Flowchart of the study
Characteristics of included studies
Table 1 provides a general description of included studies. Overall, a total of 53,134 older adults (mean age ± standard deviation [SD]= 80.1 ± 3.8 years; women= 32,006 [60.2%]) from seven countries (Argentina, Brazil, Chile, Colombia, Ecuador, Peru, and Venezuela) were studied between 2008 and 2019. Studies were based on cross-sectional, longitudinal, and cohort designs. Of the 118 included studies, 98 (83.0%; n=36,786) were performed in Brazil (6, 31, 35–130), seven (5.9%; n=6,091) in Chile (100, 131–136), five (4.2%; n=4,052) in Peru (137–141), four (3.3%; n=3,836) in Colombia (142–145), two (1.7%; n=304) in Ecuador(146,147), one (0.8%; n=100) in Argentina (148), and one (0.8%; n=1,965) in Venezuela (139).
The frailty phenotype (13) was the most commonly used tool for frailty assessment (66.6%), followed by the EFS (23.6%), the TFI (4.9%), the FRAIL scale (3.3%), the KCL (2.4%), the SOF index (0.8%), and the CFS (0.8%). Most studies (n=104; 91.5%) were conducted in community-dwellers, while nursing-home residents were evaluated in nine studies, hospitalized persons were investigated in five studies, and three studies were performed with population data. Seven studies reported the prevalence of frailty using the same sample two or more times, while three studies used more than two tools to assess frailty.
Participants were recruited in different places, including urban, rural, and areas of social vulnerability, primary and secondary healthcare centers, and community centers, to quote a few. The most common comorbidities were hypertension (33 studies), diabetes (25 studies), osteoarthritis (19 studies), cancer (17 studies), stroke (15 studies), chronic pulmonary obstructive disease (12 studies), chronic kidney disease (CKD) (10 studies), and heart failure (HF) (10 studies). Dyslipidemia, obesity, coronary heart disease, myocardial infarction, atrial fibrillation, cognitive impairment, and disability were reported in less than five studies each.
Characteristics of the included studies
CHD= Coronary heart disease; CKD= Chronic kidney disease; CPOD= Chronic pulmonary obstructive disease; CVD= Cardiovascular diseases; DS= Depressive symptoms; EFS= Edmonton frail scale; FIBRA= Fragilidade em idosos brasileiros; FRAIL= Fatigue, resistance, ambulation, illnesses, & loss of weight; HF= Heart failure; HTN= Hypertension; IHG= Isometric handgrip strength; KCL= Kihon checklist; MCI= Mild-cognitive impairment; MI= Myocardial infarction; OA= Osteoarthritis; SABE= Saúde, bem-estar e envelhecimento; SOF= Study of osteoporotic fracture; TFI= Tilburg frailty indicator; TUG= Timed “Up and Go” ; WS= Walking speed. a, b, c, d, e, f= These studies used the same sample; h, i, j, k= The same study reported the prevalence with different assesment tools
The overall score and the point-by-point analysis of quality assessment of cross-sectional and cohort studies are shown in Table 2. The overall score of cross-sectional studies ranged from 2 to 10 (maximum value: 11). All studies used a validated instrument for frailty assessment (item 4). Regarding selection criteria (item 1), 38.9% of studies used a representative sample from a random population, 21.2% did not describe the sampling strategy, 20.3% used a selected group of participants (e.g., institutionalized older adults), and 15.3% used a somewhat representative sample selected using a non-random method. The sample size (item 2) was justified in 49.5% of studies. Comparisons between respondents and non-respondents in the main characteristics (item 3) were only performed in 5.0% of the studies. Age was selected as the most important confounder factor (item 5) and it was controlled for in less than half of the studies (47.5%). Similarly, only 46.6% of studies controlled for additional factors (i.e., gender or body mass index [BMI]) (item 5). Outcomes (item 6) were assessed using an independent blind method in 56.8% of studies, self-reported scales or questionnaires in 35.2%, record linkage in 1.7%, while 1.7% did not describe the method. Finally, appropriate statistical analysis (item 7) was used in 57.8% of studies.
Quality assessment of the included studies
α= Cross-sectional study; β= Cohort study; *Max= 11 points for α and 9 points for β. Cross-sectional studies: 1) Representativeness of the sample: a) Truly representative of the average in the target population, b) Somewhat representative of the average in the target population, c) Selected group of users, d) No description of the sampling strategy; 2) Sample size: a) Justified and satisfactory, b) Not justified; 3) Non-respondents: a) Comparability between respondents and non-respondents characteristics, b) The response rate is unsatisfactory, or the comparability between respondents and non-respondents is unsatisfactory, c) No description of the response rate or the characteristics of the responders and the non-responders; 4) Ascertainment of the exposure: a) Validated measurement tool, b) Non-validated measurement tool, but the tool is available or described, c) No description of the measurement tool; 5) Comparability: a) The study controls for the most important factor, b) The study control for any additional factor; 6) Outcome: a) Independent blind assessment, b) Record linkage, c) Self report, d) No description; 7) Statistical test: a) The statistical test used to analyze the data is clearly described and appropriate, and the measurement of the association is presented, including confidence intervals and the probability level (p value), b) The statistical test is not appropriate, not described or incomplete. Cohort studies: 1) Representativeness of the exposed cohort: a) truly representative, b) somewhat representative, c) selected group of users, d) no description of the derivation of the cohort; 2) Selection of the non exposed cohort: a) drawn from the same community as the exposed cohort, b) drawn from a different source, c) no description of the derivation of the non exposed cohort; 3) Ascertainment of exposure: a) secure record (eg surgical records), b) structured interview, c) written self report, d) no description; 4) Demonstration that outcome of interest was not present at start of study: a) yes, b) no; 5) Comparability: a) study controls for age; b) study controls for any additional factor; 6) Assessment of outcome: a) independent blind assessment, b) record linkage, c) self report, d) no description; 7) Was follow-up long enough for outcomes to occur: a) yes (select an adequate follow up period for outcome of interest) b) no; 8) Adequacy of follow up of cohorts: a) complete follow up, b) subjects lost to follow up, c) no description of those lost, d) no statement
Regarding cohort studies, all of them used a structured interview to assess exposure (item 3), recruited the non-exposed cohort from the same setting as the exposed cohort (item 2), demonstrated that the outcome of interest was not present at the beginning of the study (item 4), and evaluated the outcome using an independent blind method (item 6). Seventy-five percent of the studies used a truly representative sample, and 25% a somewhat representative sample (item 1). One study did not control for any main (item 5) or additional factors. The follow-up period (item 7) was not long enough in one study and a representative sample completed the follow-up period in 75% of studies.
Prevalence of prefrailty and frailty in South America
Overall, the mean prevalence of prefrailty was 46.8%, ranging from 23.0% in Ecuador to 55.9% in Peru (Figure 2). When data were analyzed according to the assessment tool, the prevalence of prefrailty was 50.7%, 44.8%, and 18.4% for Fried, FRAIL, and EFS, respectively. The highest prevalence of prefrailty was observed in hospitalized older adults (50.7%), followed by community-dwelling persons (47.6%), and nursing-home residents (29.8%). Regarding older adults with specific conditions, people with cardiovascular disease (CVD) and CKD showed a prevalence of prefrailty of 51.2% and 26.7%, respectively.
Mean prevalence of prefrailty according to country in South America
Overall, the mean prevalence of frailty was 21.7%, ranging from 10.6% in Colombia to 31.3% in Chile (Figure 3). When data were analyzed according to the assessment tool, the prevalence of frailty was 48.8%, 38.0%, 34.7%, 26.9%, 26.0%, 18.4%, 18,2% according to TFI, SOF, Fried, KCL, CFS, EFS, and FRAIL, respectively. The highest prevalence of frailty was observed in nursing-home residents (55.8%) (supplementary Figure 4), followed by hospitalized older adults (39.1%) (supplementary Figure 5), and community-dwellers (23.0%) (supplementary Figure 6). Regarding older people with specific conditions, persons with cancer showed the highest prevalence (54.9%), followed by those with CVD (37.8%) and CKD (37.5%). The prevalence of frailty increased progressively with age (21.4% at 60-69 years, 24.5% at 70-79 years, 30.3% at 80+ years). Most studies reported a higher prevalence of frailty in women than in men.
Mean prevalence of frailty according to country in South America
Prevalence of prefrailty and frailty according to country
The mean prevalence of frailty in Argentina was 26.0%. Data were exclusively based on older patients with HF. Frailty was assessed using the CFS.
The mean prevalence of prefrailty in Brazil was 46.9%, ranging from 4.8% to 71.1%. When data were analyzed according to the assessment tool, the prevalence of prefrailty was 49.1%, 45.6%, and 19.4% for Fried, FRAIL, and EFS, respectively. The highest prevalence of prefrailty was observed in hospitalized older adults (51.0%), followed by community-dwellers (47.1%) and nursing-home residents (29.8%). Regarding older adults with specific conditions, people with CVD and CKD showed a prevalence of prefrailty of 51.2% and 26.7%, respectively.
The mean prevalence of frailty in Brazil was 26.1%, ranging from 1.9% to 75.0%. When data were analyzed according to the assessment tool, the prevalence of frailty was 48.3%, 38.0%, 34.8%, 33.1%, 26.9%, and 19.3% for TFI, SOF, FRAIL, EFS, KCL, and Fried, respectively. The highest prevalence of frailty was observed in nursing-home residents (55.8%), followed by hospitalized persons (39.6%) and community-dwellers (24.8%). Regarding older adults with specific conditions, people with cancer had the highest prevalence of frailty (57.7%), while those with CVD and CKD showed a prevalence of frailty of 37.8% and 37.5%, respectively.
The mean prevalence of prefrailty in Chile was 54.3%, ranging from 38.9% to 69.0%. The highest prevalence of prefrailty was observed in hospitalized older adults (51.0%), followed by community-dwellers (47.1%) and nursing-home residents (29.8%).
The mean prevalence of frailty in Chile was 31.3%, ranging from to 4.5% to 80.0%. When data were analyzed according to the assessment tool, Fried criteria identified a mean of 23.2% of older adults with frailty, while 80% were identified by TFI. The highest prevalence of frailty was observed in hospitalized older adults (50.0%), followed by community-dwellers (28.1%).
The mean prevalence of prefrailty and frailty in Colombia was 49.3% (12.9-53.0%) and 10.6% (7.9-12.1%), respectively. When data were analyzed according to the assessment tool, Fried criteria (44.0% and 9.6%) identified a larger number of prefrail and frail older adults compared with EFS (12.9% and 8.9%).
The mean prevalence of prefrailty and frailty in Ecuador was 57.4% and 31.2%, respectively. Data were exclusively based on older adults from the Atahualpa region. Frailty status was assessed using the TFI.
The mean prevalence of prefrailty and frailty in Chile was of 55.9% (47.3-64.6%) and 19.9% (7.7-27.7%), respectively. Older people with cancer showed a frailty prevalence of 23.8%, while 22.1% of community-dwelling older adults were frail.
The mean prevalence of frailty in Venezuela was 12.4%. Data were exclusively based on older adults from Caracas. Frailty status was assessed using the Fried criteria.
The present study investigated the prevalence of prefrailty and frailty in older adults from different settings in South America. Results from our systematic review show that about 46.8% of older people living in Brazil, Chile, Colombia, Ecuador, and Peru are prefrail. The highest prevalence of prefrailty was observed in hospitalized older adults (50.7%), followed by community-dwellers (47.6%) and nursing-home residents (29.8%). The cumulative prevalence of frailty in South America was 21.7%. The prevalence of frailty across settings differed from that of prefrailty, with the highest rate observed in nursing-home residents (55.8%), followed by hospitalized (39.1%) and community-dwelling persons (23.0%). When data were analyzed according to the geographic area, most countries showed a mean prevalence of prefrailty ~50% and a mean prevalence of frailty ~20%, with the notable exceptions of Colombia (10.6%) and Chile (31.3%).
Only one systematic review investigated the prevalence of frailty (19.6%) in South America, but results were based on a limited number of search terms, South America and Caribbean countries, and only studies with representative samples of community-dwellers were included (15). Our findings add to the existing literature by reporting the prevalence of prefrailty and frailty in older South Americans according to setting, country, and assessment tools.
Based on our results, the prevalence of frailty in the community in South America (23.0%) is almost twofold higher in comparison to Europe (12.0%)(16) and more than threefold higher than in Japan (7.4%)(18). Similarly, a higher prevalence of frailty was observed in South American nursing-home residents (55.8%) when compared with European peers (45.0%) (16). These findings are consistent with previous investigations that showed a higher prevalence of prefrailty and frailty in low- and middle-income countries compared with high-income regions (14, 15, 149). A possible explanation for this phenomenon may reside in the fact that disadvantaged socioeconomic conditions are frequently associated with inequalities in healthcare access, lower dietary quality, physical inactivity, multimorbidity and disability (150, 151), all of which contribute to the development and progression of frailty (6–8, 20).
Divergent prevalence rates of prefrailty and frailty were observed across settings, which may reflect different patterns of healthcare utilization in South America depending on the frailty status. As people progress from robustness to prefrailty, they show increased prevalence of multimorbidity (152, 153), disability (154), and risk of adverse health-related events (153), leading to higher healthcare utilization (153) and possibly hospitalization (155). In addition, muscle strength, gait speed, and balance (155, 156) are reduced in prefrail persons compared with robust older adults, which may account for increased incidence of falls (152, 154) and fractures (154) and related hospitalizations in these individuals (155).
On the other hand, frail older people show worse overall health status compared with their prefrail counterparts (152), which make them need more time to recover from stressful events, increasing the use of critical care services (157) and frequent hospital readmission (158). Mortality is a frequent outcome in hospitalized frail older adults (158), and nursing-home allocation is a common discharge disposition for survivors (158). Indeed, frailty is highly prevalent in nursing-homes (11, 159), possibly reflecting the increased need of medical attention (157) as well as cognitive decline (155, 159), and disabilities of residents (160).
According to Ofori-Asenso et al. (14), the 3-year frailty incidence rate among prefrail individuals worldwide is 62.7 cases per 1000 person-years, which might suggest that more than one million new cases of frailty may be expected in South America each year. This figure has relevant public health implications and calls for immediate actions against frailty in South America. Indeed, the early detection of prefrailty and frailty may reduce the risk for negative health-related outcomes and healthcare utilization through the design and implementation of person-tailored interventions (161).
Strategies to reverse frailty should be devised according to frailty status and setting. Community-dwellers showed the lowest prevalence of frailty (23.0%), while almost one-in-two (47.6%) was classified as prefrail. Older adults living in the community are commonly able to perform activities of daily living (ADL) and, consequently, might benefit from long-term interventions that need more engagement, such as exercise programs (162, 163) and dietary counseling (164–166). Hence, public health policies for this population may include group-based multicomponent exercise programs aimed at improving physical performance (167–169) and dietary support. Personalized interventions may be required by hospitalized older adults and nursing-home residents, given the complexity of their clinical conditions, the high prevalence of multimorbidity and disability, and the high mortality rates (170–173).
Quality assessment analysis indicates a high prevalence of selecting, inclusive, and reporting biases. The main limitations included small sample size, sampling strategy, and lack of clinical information. Future observational studies should be conducted taking into account the above-mentioned issues.
Our study is not free of limitations. First, although our findings are based on the majority of Latin American countries, limited evidence was available for most of them, except for Brazil. Indeed, no studies were retrieved that investigated the prevalence of prefrailty and frailty in Bolivia, Paraguay, Uruguay, Guyana and Suriname, and only few reports were available for Argentina, Venezuela and Ecuador. Second, although unlikely, it is possible that more studies could be available in other databases than those used for the present study. However, selected databases have wide coverage without losing the quality of journals. Third, the cross-sectional design of included studies limits extrapolation and interpretation of findings.
Prefrailty and frailty are highly prevalent in South American older adults, with rates higher than in Europe and Asia. Among community-dwellers, almost one-in-two is prefrail and one-in-five is frail, while hospitalized older adults and nursing-home residents are more often affected. These findings call for immediate actions to ensure sustainability of healthcare systems. Hence, our report may provide basic information for healthcare authorities and policy makers to devise novel models of care responsive to emerging medical needs of older South Americans.
Conflicts of Interest: Authors report no conflict of interests.
Acknowledgements: The authors are grateful to the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES; Finance Code 001) for a scholarship granted to Hélio José Coelho Júnior.
1. Collard RM, Boter H, Schoevers RA, Oude Voshaar RC. Prevalence of Frailty in Community-Dwelling Older Persons: A Systematic Review. J Am Geriatr Soc. 2012;60(8):1487–92.
2. van Kan GA, Rolland Y, Houles M, Gillette-Guyonnet S, Soto M, Vellas B. The Assessment of Frailty in Older Adults. Clin Geriatr Med. 2010;26(2):275–86.
3. Clegg A, Young J, Iliffe S, Rikkert MO, Rockwood K. Frailty in elderly people. Lancet. 2013;381(9868):752–62.
4. Morley JE, Malmstrom TK. Frailty, sarcopenia, and hormones. Endocrinol Metab Clin North Am. 2013;42(2):391–405.
5. Choi J, Ahn A, Kim S, Won CW. Global Prevalence of Physical Frailty by Fried’s Criteria in Community-Dwelling Elderly With National Population-Based Surveys. J Am Med Dir Assoc. 2015;16(7):548–50.
6. Gomes CDS, Guerra RO, Wu YY, Barbosa JFS, Gomez F, Sousa ACPA, et al. Social and Economic Predictors of Worse Frailty Status Occurrence Across Selected Countries in North and South America and Europe. Innov Aging. 2018;2(3):igy037.
7. Franse CB, van Grieken A, Qin L, Melis RJF, Rietjens JAC, Raat H. Socioeconomic inequalities in frailty and frailty components among community-dwelling older citizens. PLoS One. 2017;12(11):e0187946.
8. Hanlon P, Nicholl BI, Jani BD, Lee D, McQueenie R, Mair FS. Frailty and pre-frailty in middle-aged and older adults and its association with multimorbidity and mortality: a prospective analysis of 493 737 UK Biobank participants. Lancet Public Health. 2018;3(7):e323–32.
9. Kojima G. Frailty as a predictor of hospitalisation among community-dwelling older people: a systematic review and meta-analysis. J Epidemiol Community Health. 2016;70(7):722–9.
10. Kojima G. Frailty significantly increases the risk of fractures among middle-aged and older people. Evid Based Nurs. 2017;20(4):119–20.
11. Kojima G. Prevalence of Frailty in Nursing Homes: A Systematic Review and Meta-Analysis. J Am Med Dir Assoc. 2015;16(11):940–5.
12. Hajek A, Bock J-O, Saum K-U, Matschinger H, Brenner H, Holleczek B, et al. Frailty and healthcare costs-longitudinal results of a prospective cohort study. Age Ageing. 2018;47(2):233–41.
13. Fried LP, Tangen CM, Walston J, Newman AB, Hirsch C, Gottdiener J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001;56(3):M146-56.
14. Ofori-Asenso R, Chin KL, Mazidi M, Zomer E, Ilomaki J, Zullo AR, et al. Global Incidence of Frailty and Prefrailty Among Community-Dwelling Older Adults. JAMA Netw Open. 2019;2(8):e198398.
15. Da Mata FA, Pereira PP, Andrade KR, Figueiredo AC, Silva MT, Pereira MG. Prevalence of Frailty in Latin America and the Caribbean: A Systematic Review and Meta-Analysis. PLoS One. 2016;11(8):e0160019.
16. O’Caoimh R, Galluzzo L, Rodríguez-Laso Á, Van der Heyden J, Ranhoff AH, Lamprini-Koula M, et al. Prevalence of frailty at population level in European ADVANTAGE Joint Action Member States: a systematic review and meta-analysis. Ann Ist Super Sanita. 54(3):226–38.
17. Manfredi G, Midão L, Paúl C, Cena C, Duarte M, Costa E. Prevalence of frailty status among the European elderly population: Findings from the Survey of Health, Aging and Retirement in Europe. Geriatr Gerontol Int. 2019;9(8):723–29.
18. Kojima G, Iliffe S, Taniguchi Y, Shimada H, Rakugi H, Walters K. Prevalence of frailty in Japan: A systematic review and meta-analysis. J Epidemiol. 2017;27(8):347–53.
19. de Carvalho Mello A, Montenegro Engstrom E, Correia Alves L. Health-related and socio-demographic factors associated with frailty in the elderly: a systematic literature review. Cad Saude Publica. 2014;30(6):1143–68.
20. Feng Z, Lugtenberg M, Franse C, Fang X, Hu S, Jin C, et al. Risk factors and protective factors associated with incident or increase of frailty among community-dwelling older adults: A systematic review of longitudinal studies. PLoS One. 2017;12(6):e0178383.
21. Vermeiren S, Vella-Azzopardi R, Beckwée D, Habbig A-K, Scafoglieri A, Jansen B, et al. Frailty and the Prediction of Negative Health Outcomes: A Meta-Analysis. J Am Med Dir Assoc. 2016;17(12):1163.e1-1163.e17.
22. Morley JE, Vellas B, Abellan van Kan G, Anker SD, Bauer JM, Bernabei R, et al. Frailty Consensus: A Call to Action. J Am Med Dir Assoc. 2013;14(6):392–7.
23. Turner G, Clegg A, British Geriatrics Society, Age UK, Royal College of General Practioners. Best practice guidelines for the management of frailty: a British Geriatrics Society, Age UK and Royal College of General Practitioners report. Age Ageing. 2014;43(6):744–7.
24. Dent E, Lien C, Lim WS, Wong WC, Wong CH, Ng TP, et al. The Asia-Pacific Clinical Practice Guidelines for the Management of Frailty. J Am Med Dir Assoc. 2017;18(7):564–75.
25. WHO. Global Health and Aging. 2015 (accessed on March 5, 2020), available at https://www.who.int/ageing/publications/global_health.pdf.
26. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Ioannidis JPA, et al. The PRISMA Statement for Reporting Systematic Reviews and Meta-Analyses of Studies That Evaluate Health Care Interventions: Explanation and Elaboration. PLoS Med. 2009;6(7):e1000100.
27. Santiago LM, Luz LL, Mattos IE, Gobbens RJJ, van Assen MALM. Psychometric properties of the Brazilian version of the Tilburg frailty indicator (TFI). Arch Gerontol Geriatr. 2013;57(1):39–45.
28. Morley JE, Malmstrom TK, Miller DK. A simple frailty questionnaire (FRAIL) predicts outcomes in middle aged African Americans. J Nutr Health Aging. 2012;16(7):601–8.
29. Sewo Sampaio PY, Sampaio RAC, Yamada M, Arai H. Systematic review of the Kihon Checklist: Is it a reliable assessment of frailty? Geriatr Gerontol Int. 2016;16(8):893–902.
30. Ensrud KE, Ewing SK, Taylor BC, Fink HA, Cawthon PM, Stone KL, et al. Comparison of 2 Frailty Indexes for Prediction of Falls, Disability, Fractures, and Death in Older Women. Arch Intern Med. 2008;168(4):382.
31. Fabrício-Wehbe SCC, Schiaveto FV, Vendrusculo TRP, Haas VJ, Dantas RAS, Rodrigues RAP. Cross-cultural adaptation and validity of the "Edmonton Frail Scale – EFS" in a Brazilian elderly sample. Rev Lat Am Enfermagem. 2009;17(6):1043–9.
32. Rockwood K, Song X, MacKnight C, Bergman H, Hogan DB, McDowell I, et al. A global clinical measure of fitness and frailty in elderly people. CMAJ. 2005;173(5):489–95.
33. Modesti PA, Reboldi G, Cappuccio FP, Agyemang C, Remuzzi G, Rapi S, et al. Panethnic Differences in Blood Pressure in Europe: A Systematic Review and Meta-Analysis. PLoS One. 2016;11(1):e0147601.
34. Wells GA, Shea B, O’Connell DO, Peterson J, Welch V, Losos M, et al. Newcastle-Ottawa Scale (NOS). 2019 (accessed on March 5, 2020), available at http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp.
35. Bôas NCRV, Salomé GM, Ferreira LM. Frailty syndrome and functional disability among older adults with and without diabetes and foot ulcers. J Wound Care. 2018;27(7):409–16.
36. Fernandes Bolina A, Rodrigues RAP, Tavares DM dos S, Haas VJ. Factors associated with the social, individual and programmatic vulnerability of older adults living at home. Rev da Esc Enferm da USP. 2019;53:e03429.
37. Brigola AG, Luchesi BM, Alexandre TDS, Inouye K, Mioshi E, Pavarini SCI. High burden and frailty: association with poor cognitive performance in older caregivers living in rural areas. Trends Psychiatry Psychother. 2017;39(4):257–63.
38. Pavarini SCI, Neri AL, Brigola AG, Ottaviani AC, Souza ÉN, Rossetti ES, et al. Elderly caregivers living in urban, rural and high social vulnerability contexts. Rev da Esc Enferm. 2017;51:e03254.
39. Carneiro JA, Ramos GCF, Barbosa ATF, Medeiros SM, de Almeda Lima C, da Costa FM, et al. Prevalência e fatores associados à incontinência urinária em idosos não institucionalizados. Cad Saúde Coletiva. 2017;25(3):268–77.
40. Carneiro JA, Ramos GCF, Barbosa ATF, de Mendonça JMG, da Costa FM, Caldeira AP, et al. Prevalência e fatores associados à fragilidade em idosos não institucionalizados. Rev Bras Enferm. 2016;69(3):435–42.
41. de Carvalho Mello A, Carvalho MS, Correia Alves L, Gomes VP, Engstrom EM. Consumo alimentar e antropometria relacionados à síndrome de fragilidade em idosos residentes em comunidade de baixa renda de um grande centro urbano. Cad Saude Publica. 2017;33(8):e00188815.
42. Cezar NOC, Izbicki R, Cardoso D, Almeida JG, Valiengo L, Camargo MVZ, et al. Frailty in older adults with amnestic mild cognitive impairment as a result of Alzheimer’s disease: A comparison of two models of frailty characterization. Geriatr Gerontol Int. 2017;17(11):2096–102.
43. da Silva Coqueiro R, de Queiroz BM, Oliveira DS, das Merces MC, Oliveira Carneiro JA, Pereira R, et al. Cross-sectional relationships between sedentary behavior and frailty in older adults. J Sports Med Phys Fitness. 2017;57(6):825–30.
44. Cordeiro LM, de Lima Paulino J, Bessa MEP, Borges CL, Leite SFP, Cordeiro LM, et al. Qualidade de vida do idoso fragilizado e institucionalizado. Acta Paul Enferm. 2015;28(4):361–6.
45. Alencar MA, Dias JMD, Figueiredo LC, Dias RC. Frailty and cognitive impairment among community-dwelling elderly. Arq Neuropsiquiatr. 2013;71(6):362–7.
46. Corona LP, Pereira de Brito TR, Nunes DP, da Silva Alexandre T, Ferreira Santos JL, de Oliveira Duarte YA, et al. Nutritional status and risk for disability in instrumental activities of daily living in older Brazilians. Public Health Nutr. 2014;17(2):390–5.
47. da Graça Oliveira Crossetti M, Antunes M, Waldman BF, Unicovsky MAR, de Rosso LH, Lana LD, et al. Factors that contribute to a NANDA nursing diagnosis of risk for frail elderly syndrome. Rev Gaúcha Enferm. 2018;39:e2017-0233.
48. Cruz DTD, Vieira MT, Bastos RR, Leite ICG. Factors associated with frailty in a community-dwelling population of older adults. Rev Saude Publica. 2017;51:106.
49. da Silva SLA, Vieira RA, Arantes P, Dias RC. Avaliação de fragilidade, funcionalidade e medo de cair em idosos atendidos em um serviço ambulatorial de geriatria e gerontologia. Fisioter Pesqui. 2009;16(2):120–5.
50. da Silva V, Tribess S, Meneguci J, Sasaki J, Santos D, Carneiro J, et al. Time Spent in Sedentary Behaviour as Discriminant Criterion for Frailty in Older Adults. Int J Environ Res Public Health. 2018;15(7):1336.
51. de Andrade FB, Lebrão ML, Santos JLF, de Oliveira Duarte YA. Relationship Between Oral Health and Frailty in Community-Dwelling Elderly Individuals in Brazil. J Am Geriatr Soc. 2013;61(5):809–14.
52. de Amorim JSC, da Silva SLA, Ude Viana J, Trelha CS. Factors associated with the prevalence of sarcopenia and frailty syndrome in elderly university workers. Arch Gerontol Geriatr. 2019;82:172–8.
53. Mendonça De Melo D, Falsarella GR, Neri AL. Autoavaliação de saúde, envolvimento social e fragilidade em idosos ambulatoriais. Self-rated health, social involvement and frailty in elderly outpatients. Rev. Bras. Geriatr. Gerontol. 2014;17(3):471–84.
54. de Sousa JAV, Lenardt MH, Grden CRB, Kusomota L, Dellaroza MSG, Betiolli SE, et al. Physical frailty prediction model for the oldest old. Rev Lat Am Enfermagem. 2018;26:e3023.
55. dos Santos AA, Ceolim MF, Pavarini SCI, Neri AL, Rampazo MK. Associação entre transtornos do sono e níveis de fragilidade entre idosos. Acta Paul Enferm. 2014;27(2):120–5.
56. Aprahamian I, Lin SM, Suemoto CK, Apolinario D, Oiring de Castro Cezar N, Elmadjian SM, et al. Feasibility and Factor Structure of the FRAIL Scale in Older Adults. J Am Med Dir Assoc. 2017;18(4):367.e11-367.e18.
57. Duarte MCS, das Graças Melo Fernandes M, Rodrigues RAP, da Nóbrega MML. Prevalência e fatores sociodemográficos associados à fragilidade em mulheres idosas. Rev Bras Enferm. 2013;66(6):901–6.
58. Falsarella GR, Gasparotto LPR, Barcelos CC, Coimbra IB, Moretto MC, Pascoa MA, et al. Body composition as a frailty marker for the elderly community. Clin Interv Aging. 2015;10:1661.
59. Farías-Antúnez S, Fassa AG, Farías-Antúnez S, Fassa AG. Prevalência e fatores associados à fragilidade em população idosa do Sul do Brasil, 2014*. Epidemiol e Serviços Saúde. 2019;28(1):e2017405.
60. Fluetti MT, Roberto J, Fhon S, De Oliveira PA, Martins L, Chiquito O, et al. Síndrome da fragilidade em idosos institucionalizados The frailty syndrome in institutionalized elderly persons. Rev. Bras. Geriatr. Gerontol. 2018:21(1):60–9,
61. Filippin LI, Miraglia F, Carvalho Leite JC, Chakr R, Cardoso Oliveira N, Berwanger DD. Identifying frailty syndrome with TUG test in home-dwelling elderly. Identificação da síndrome da fragilidade com o teste TUG em idosos residentes na comunidade. Geriatr Gerontol Aging. 2017;11(2):80.
62. Freitas CV, do Socorro Nascimento Falcão Sarges E, Santana Moreira KEC, Carneiro SR. Evaluation of frailty, functional capacity and quality of life of the elderly in geriatric outpatient clinic of a university hospital. Rev Bras Geriatr Gerontol. 2016;19(1):119–28.
63. Frisoli A, Ingham SJM, Paes ÂT, Tinoco E, Greco A, Zanata N, et al. Frailty predictors and outcomes among older patients with cardiovascular disease: Data from Fragicor. Arch Gerontol Geriatr. 2015;61(1):1–7.
64. da Costa Lima Fernandes H, Gaspar JC, Yamashita CH, Amendola F, Alvarenga MRM, de Campos Oliveira MA. Avaliação da fragilidade de idosos atendidos em uma unidade da Estratégia Saúde da Família. Texto Context – Enferm. 2013;22(2):423–31.
65. Fhon JRS, Diniz MA, Leonardo KC, Kusumota L, Rodrigues RAP, Haas VJ. Frailty syndrome related to disability in the elderly. Acta Paul Enferm. 2012;25(4):589–94.
66. Gesualdo GD, Zazzetta MS, Say KG, de Souza Orlandi F. Fatores associados à fragilidade de idosos com doença renal crônica em hemodiálise. Cien Saude Colet. 2016;21(11):3493–8.
67. Aprahamian I, Cezar NOC, Izbicki R, Lin SM, Paulo DLV, Fattori A, et al. Screening for Frailty With the FRAIL Scale: A Comparison With the Phenotype Criteria. J Am Med Dir Assoc. 2017;18(7):592–6.
68. Gross CB, Kolankiewicz ACB, Schmidt CR, Berlezi EM, Gross CB, Kolankiewicz ACB, et al. Níveis de fragilidade de idosos e sua associação com as características sociodemográficas. Acta Paul Enferm. 2018;31(2):209–16.
69. Grden CRB, Lenardt MH, de Sousa JAV, Kusomota L, Dellaroza MSG, Betiolli SE, et al. Associations between frailty syndrome and sociodemographic characteristics in long-lived individuals of a community. Rev Lat Am Enfermagem. 2017;25:e2886.
70. Holanda CM, Guerra RO, Nóbrega PV, Costa HF, Piuvezam MR, Maciel ÁC. Salivary cortisol and frailty syndrome in elderly residents of long-stay institutions: A cross-sectional study. Arch Gerontol Geriatr. 2012;54(2):e146–51.
71. de Jesus ITM, dos Santos Orlandi AA, Grazziano E da S, Zazzetta MS. Fragilidade de idosos em vulnerabilidade social. Acta Paul Enferm. 2017;30(6):614–20.
72. de Jesus ITM, Orlando FS, Zazzetta MS. Frailty and cognitive performance of elderly in the context of social vulnerability. Dement Neuropsychol. 2018;12(2):173–80.
73. de Jesus ITM, Diniz MAA, Lanzotti RB, Orlandi FS, Pavarin SCI, Zazzetta MS. Fragilidade e qualidade de vida de idosos em contexto de vulnerabilidade social. Texto Context – Enferm. 2018;27(4):e4300016.
74. Lealdini V, Trufelli DC, da Silva FBF, Normando SRC, Camargo EW, Matos LL, et al. Applicability of modified Glasgow Prognostic Score in the assessment of elderly patients with cancer: A pilot study. J Geriatr Oncol. 2015;6(6):479–83.
75. Lenardt MH, Carneiro NHK, Binotto MA, Setoguchi LS, Cechinel C, Lenardt MH, et al. The relationship between physical frailty and sociodemographic and clinical characteristics of elderly. Esc Anna Nery – Rev Enferm. 2015;19(4):585–92.
76. Lenardt MH, Kozlowski Cordeiro Garcia AC, Binotto MA, Hammerschmidt Kolb Carneiro N, Lourenço TM, Cechinel C. Non-frail elderly people and their license to drive motor vehicles. Ancianos no frágiles y la habilitación para conducir vehículos automotores. Rev Bras Enferm. 2018;71(2):373–82.
77. Lin SM, Aliberti MJR, Fortes-Filho SQ, Melo JA, Aprahamian I, Suemoto CK, et al. Comparison of 3 Frailty Instruments in a Geriatric Acute Care Setting in a Low-Middle Income Country. J Am Med Dir Assoc. 2018;19(4):310-314.e3.
78. Aprahamian I, Suemoto CK, Aliberti MJR, de Queiroz Fortes Filho S, de Araújo Melo J, Lin SM, et al. Frailty and cognitive status evaluation can better predict mortality in older adults? Arch Gerontol Geriatr. 2018;77:51–6.
79. de Llano PMP, Lange C, Nunes DP, Pastore CA, Pinto AH, Casagranda LP. Fragilidade em idosos da zona rural: proposta de algoritmo de cuidados. Acta Paul Enferm. 2017;30(5):520–30.
80. Lustosa LP, Marra TA, dos Santos Pessanha FPA, de Carvalho Freitas J, de Cássia Guedes R. Fragilidade e funcionalidade entre idosos frequentadores de grupos de convivência em Belo Horizonte, MG. Rev Bras Geriatr Gerontol. 2013;16(2):347–54.
81. de Albuquerque Melo EM, de Oliveira Marques AP, Leal MCC, de Albuquerque Melo HM. Síndrome da fragilidade e fatores associados em idosos residentes em instituições de longa permanência. Saúde em Debate. 2018;42(117):468–80.
82. Medeiros SM, Silva LSR, Carneiro JA, Ramos GCF, Barbosa ATF, Caldeira AP, et al. Fatores associados à autopercepção negativa da saúde entre idosos não institucionalizados de Montes Claros, Brasil. Cien Saude Colet. 2016;21(11):3377–86.
83. de Morais D, Terassi M, Inouye K, Luchesi BM, Pavarini SCI. Dor crônica de idosos cuidadores em diferentes níveis de fragilidade. Rev Gaúcha Enferm. 2016;37(4):e60700.
84. de Souza Moreira B, Dos Anjos DM, Pereira DS, Sampaio RF, Pereira LS, Dias RC, et al. The geriatric depression scale and the timed up and go test predict fear of falling in community-dwelling elderly women with type 2 diabetes mellitus: a cross-sectional study. BMC Geriatr. 2016;16(1):56.
85. Nascimento CMC, Zazzetta MS, Gomes GAO, Orlandi FS, Gramani-Say K, Vasilceac FA, et al. Higher levels of tumor necrosis factor β are associated with frailty in socially vulnerable community-dwelling older adults. BMC Geriatr. 2018;18(1):268.
86. Neri AL, Yassuda MS, de Araújo LF, do Carmo Eulálio M, Cabral BE, de Siqueira MEC, et al. Metodologia e perfil sociodemográfico, cognitivo e de fragilidade de idosos comunitários de sete cidades brasileiras: Estudo FIBRA. Cad Saude Publica. 2013;29(4):778–92.
87. de Queiroz Neves A, da Silva AMC, Cabral JF, Mattos IE, Santiago LM. Prevalence of and factors associated with frailty in elderly users of the Family Health Strategy. Rev Bras Geriatr e Gerontol. 2018;21(6):680–90.
88. Nóbrega PV, Maciel AC, de Almeida Holanda CM, Oliveira Guerra R, Araújo JF. Sleep and frailty syndrome in elderly residents of long-stay institutions: A cross-sectional study. Geriatr Gerontol Int. 2014;14(3):605–12.
89. Augusti ACV, Falsarella GR, Coimbra AMV. Análise da síndrome da fragilidade em idosos na atenção primária – Estudo transversal. Rev Bras Med Família Comunidade. 2017;12(39):1–9.
90. de Sousa Orlandi F, Gesualdo GD. Assessment of the frailty level of elderly people with chronic kidney disease undergoing hemodialysis. Acta Paul Enferm. 2014;27(1):29–34.
91. Oliveira DR, Bettinelli LA, Pasqualotti A, Corso D, Brock F, Erdmann AL. Prevalence of frailty syndrome in old people in a hospital institution. Rev Lat Am Enfermagem. 2013;21(4):891–8.
92. Parentoni AN, Lustosa LP, dos Santos KD, Sá LF, Ferreira FO, Mendonça VA. Comparação da força muscular respiratória entre os subgrupos de fragilidade em idosas da comunidade. Fisioter Pesqui. 2013;20(4):361–6.
93. Pegorari MS, Ruas G, Patrizzi LJ. Relationship between frailty and respiratory function in the community-dwelling elderly. Brazilian J Phys Ther. 2013;17(1):9–16.
94. Pegorari MS, Tavares DM. Factors associated with the frailty syndrome in elderly individuals living in the urban area. Rev Lat Am Enfermagem. 2014;22(5):874–82.
95. Ramos GCF, Carneiro JA, Barbosa ATF, Mendonça JMG, Caldeira AP. Prevalência de sintomas depressivos e fatores associados em idosos no norte de Minas Gerais: um estudo de base populacional. J Bras Psiquiatr. 2015;64(2):122–31.
96. Ricci N, Silva Pessoa G, Ferrioli E, Correa Dias R, Rodrigues Perracini M. Frailty and cardiovascular risk in community-dwelling elderly: a population-based study. Clin Interv Aging. 2014;1677.
97. Rossetti ES, Terassi M, Ottaviani AC, dos Santos-Orlandi AA, Pavarini SCI, Zazzetta MS. Fragilidade, sintomas depressivos e sobrecarga de idosos cuidadores em contexto de alta vulnerabilidade social. Texto Context – Enferm. 2018;27(3):e3590016.
98. Santiago LM, Mattos IE, Santiago LM, Mattos IE. Prevalência e fatores associados à fragilidade em idosos institucionalizados das regiões Sudeste e Centro-Oeste do Brasil. Rev Bras Geriatr e Gerontol. 2014;17(2):327–37.
99. Santiago LM, Luz LL, Mattos IE, Gobbens RJJ, van Assen MALM. Psychometric properties of the Brazilian version of the Tilburg frailty indicator (TFI). Arch Gerontol Geriatr. 2013;57(1):39–45.
100. Alvarado BE, Zunzunegui M-V, Béland F, Bamvita J-M. Life course social and health conditions linked to frailty in Latin American older men and women. J Gerontol A Biol Sci Med Sci. 2008;63(12):1399–406.
101. Santiago LM, Gobbens RJJ, van Assen MALM, Carmo CN, Ferreira DB, Mattos IE. Predictive validity of the Brazilian version of the Tilburg Frailty Indicator for adverse health outcomes in older adults. Arch Gerontol Geriatr. 2018;76:114–9.
102. Santiago LM, Gobbens RJJ, Mattos IE, Ferreira DB. A comparison between physical and biopsychosocial measures of frailty: Prevalence and associated factors in Brazilian older adults. Arch Gerontol Geriatr. 2019;81:111–8.
103. Sampaio LS, Carneiro JAO, da Silva Coqueiro R, Fernandes MH. Indicadores antropométricos como preditores na determinação da fragilidade em idosos. Cien Saude Colet. 2017;22(12):4115–24.
104. dos Santos Tavares DM, Nader ID, de Paiva MM, Dias FA, Pegorari MS. Association of socioeconomic and clinical variables with the state of frailty among older inpatients. Rev Lat Am Enfermagem. 2015;23(6):1121–9.
105. de Souza Santos PL, Fernandes MH, Santos PHS, Santana TDB, Cassoti CA, Coqueiro RDS, et al. Indicadores de desempenho motor como preditores de fragilidade em idosos cadastrados em uma Unidade de Saúde da Família. Motricidade. 2016;12(2):88.
106. Sewo Sampaio PY, Sampaio RAC, Yamada M, Ogita M, Arai H. Validation and translation of the Kihon Checklist (frailty index) into Brazilian Portuguese. Geriatr Gerontol Int. 2014;14(3):561–9.
107. Sewo Sampaio PY, Sampaio RAC, Coelho Júnior HJ, Teixeira LFM, Tessutti VD, Uchida MC, et al. Differences in lifestyle, physical performance and quality of life between frail and robust Brazilian community-dwelling elderly women. Geriatr Gerontol Int. 2016;16(7).
108. Sampaio PYS, Sampaio RAC, Yamada M, Ogita M, Arai H. Comparison of frailty among Japanese, Brazilian Japanese descendants and Brazilian community-dwelling older women. Geriatr Gerontol Int. 2015;15(6):762–9.
109. dos Santos-Orlandi AA, de Brito TRP, Ottaviani AC, Rossetti ES, Zazzetta MS, Pavarini SCI, et al. Elderly who take care of elderly: a study on the Frailty Syndrome. Rev Bras Enferm. 2017;70(4):822–9.
110. de Albuquerque Sousa ACP, Dias RC, Maciel ÁCC, Guerra RO. Frailty syndrome and associated factors in community-dwelling elderly in Northeast Brazil. Arch Gerontol Geriatr. 2012;54(2):e95–101.
111. Belisário MS, Dias FA, Pegorari MS, de Paiva MM, dos Santos Ferreira PC, Corradini FA, et al. Cross-sectional study on the association between frailty and violence against community-dwelling elderly people in Brazil. Sao Paulo Med J. 2017;136(1):10–9.
112. Storti LB, Fabrício-Whebe SCC, Kusumota L, Rodrigues RAP, Marques S. Fragilidade de idosos internados na clínica médica da unidade de emergência de um hospital geral terciário. Texto Context – Enferm. 2013;22(2):452–9.
113. Silveira T, Pegorari MS, de Castro SS, Ruas G, Novais-Shimano SG, Patrizzi LJ. Association of falls, fear of falling, handgrip strength and gait speed with frailty levels in the community elderly. Med (Ribeirao Preto Online). 2015;48(6):549.
114. dos Santos Tavares DM, Colamego CG, Pegorari MS, dos Santos Ferreira PC, Dias FA, Bolina AF, et al. Cardiovascular risk factors associated with frailty syndrome among hospitalized elderly people: a cross-sectional study. Sao Paulo Med J. 2016;134(5):393–9.
115. dos Santos Tavares DM, Freitas Corrêa TA, Aparecida Dias F, dos Santos Ferreira PC, Sousa Pegorari M. Frailty syndrome and socioeconomic and health characteristics among older adults. Colomb Med. 2017;v48(i3):126–31.
116. dos Santos Tavares DM, Faria PM, Pegorari MS, dos Santos Ferreira PC, Nascimento JS, Marchiori GF. Frailty Syndrome in Association with Depressive Symptoms and Functional Disability among Hospitalized Elderly. Issues Ment Health Nurs. 2018;39(5):433–8.
117. Teixeira-Gasparini E, Partezani-Rodrigues R, Fabricio-Wehbe S, Silva-Fhon J, Aleixo-Diniz M, Kusumota L. Uso de tecnologías de asistencia y fragilidad en adultos mayores de 80 años y más. Enfermería Univ. 2016;13(3):151–8.
118. Zukeran MS, Ritti-Dias RM, Franco FGM, Cendoroglo MS, de Matos LDN, Lima Ribeiro SM. Nutritional Risk by Mini Nutritional Assessment (MNA), but not Anthropometric Measurements, has a Good Discriminatory Power for Identifying Frailty in Elderly People: Data from Brazilian Secondary Care Clinic. J Nutr Health Aging. 2019;23(2):217–20.
119. Viana JU, Silva SLA, Torres JL, Dias JMD, Pereira LSM, Dias RC, et al. Influence of sarcopenia and functionality indicators on the frailty profile of community-dwelling elderly subjects: a cross-sectional study. Brazilian J Phys Ther. 2013;17(4):373–81.
120. Zazzetta MS, Gomes GAO, Orlandi FS, Gratão ACM, Vasilceac FA, Gramani-Say K, et al. Identifying Frailty Levels and Associated Factors in a Population Living in the Context of Poverty and Social Vulnerability. J Frailty Aging. 2017;6(1):29–32.
121. Vieira GÂCM, Costa EP, Medeiros ACT, Costa MML, Rocha FAT. Avaliação da fragilidade em idosos participantes de um centro de convivência Evaluation of fragility in elderly participants of a community center. Rev Pesqui Cuid Fundam Online. 2017;9(1):114.
122. Binotto MA, Lenardt MH, Carneiro NHK, Lourenço TM, Cechinel C, del Carmen Rodríguez-Martínez M, et al. Fatores associados à velocidade da marcha em idosos submetidos aos exames para habilitação veicular. Rev Lat Am Enfermagem. 2019;27: e3138.
123. da Costa Alves EV, Flesch LD, Cachioni M, Neri AL, Batistoni SST. The double vulnerability of elderly caregivers: multimorbidity and perceived burden and their associations with frailty. Rev Bras Geriatr Gerontol. 2018;21(3):301–11.
124. Borges CL, da Silva MJ, Clares JWB, Bessa MEP, de Freitas MC. Avaliação da fragilidade de idosos institucionalizados. Acta Paul Enferm. 2013;26(4):318–22.
125. da Silva VD, Tribess S, Meneguci J, Sasaki JE, Garcia-Meneguci CA, Carneiro JAO, et al. Association between frailty and the combination of physical activity level and sedentary behavior in older adults. BMC Public Health. 2019;19(1):709.
126. Borges CL, da Silva MJ, Clares JWB, Nogueira JDM, de Freitas MC. Características sociodemográficas e clínicas de idosos institucionalizados: contribuições para o cuidado de enfermagem. Rev Enferm UERJ. 2015;23(3):381–7.
127. Almeida J, Rodrigues R, Durães S, Clara M, Guedes A, Santos FL. Fragilidade em idosos: prevalência e fatores associados. Rev Bras Enferm. 2017;70:780–5.
128. Almeida Carneiro J, Carmen Fagundes Ramos G, Teresa Fernandes Barbosa A, Débora Souza Vieira E, Santos Rocha Silva J, Prates Caldeira A. Quedas em idosos não institucionalizados no norte de Minas Gerais: prevalência e fatores associados. Rev Bras Geriatr. Gerontol. 2016;19(4):613–25.
129. Carvalho TC, do Valle AP, Jacinto AF, de Sá Mayoral VF, Boas PJFV. Impact of hospitalization on the functional capacity of the elderly: A cohort study. Rev Bras Geriatr e Gerontol. 2018;21(2):134–42.
130. Santos PHS, Fernandes MH, Casotti CA, da Silva Coqueiro R, Carneiro JAO. Perfıl de fragilidade e fatores associados em idosos cadastrados em uma Unidade de Saúde da Família. Cien Saude Colet. 2015;20(6):1917–24.
131. Albala C, Lera L, Sanchez H, Angel B, Márquez C, Arroyo P, et al. Frequency of frailty and its association with cognitive status and survival in older Chileans. Clin Interv Aging. 2017;12:995–1001.
132. Araya AX, Herrera MS, Iriarte E, Rioja R. Evaluación de la funcionalidad y fragilidad de las personas mayores asistentes a centros de día. Rev Med Chil. 2018;146(8):864–71.
133. Bustamante-Ara N, Villarroel L, Paredes F, Huidobro A, Ferreccio C. Frailty and health risks in an agricultural population, Chile 2014–2017. Arch Gerontol Geriatr. 2019;82:114–9.
134. Díaz-Toro F, Nazzal Nazal C, Verdejo H, Rossel Ví, Castro P, Larrea R, et al. Factores asociados a fragilidad en pacientes hospitalizados con insuficiencia cardiaca descompensada. Rev Med Chil. 2017;145(2):164–71.
135. Palomo I, Giacaman RA, León S, Lobos G, Bustamante M, Wehinger S, et al. Analysis of the characteristics and components for the frailty syndrome in older adults from central Chile. The PIEI-ES study. Arch Gerontol Geriatr. 2019;80:70–5.
136. Tapia P C, Valdivia-Rojas Y, Varela V H, Carmona G A, Iturra M V, Jorquera C M. Indicadores de fragilidad en adultos mayores del sistema público de salud de la ciudad de Antofagasta. Rev Med Chil. 2015;143(4):459–66.
137. At J, Bryce R, Prina M, Acosta D, Ferri CP, Guerra M, et al. Frailty and the prediction of dependence and mortality in low- and middle-income countries: a 10/66 population-based cohort study. BMC Med. 2015;13(1):138.
138. Varela Pinedo L, Ortiz Saavedra PJ, Chávez Jimeno H. Velocidad de la marcha como indicador de fragilidad en adultos mayores de la comunidad en Lima, Perú. Rev Esp Geriatr Gerontol. 2010;45(1):22–5.
139. Llibre Rodriguez JJ, Prina AM, Acosta D, Guerra M, Huang Y, Jacob KS, et al. The Prevalence and Correlates of Frailty in Urban and Rural Populations in Latin America, China, and India: A 10/66 Population-Based Survey. J Am Med Dir Assoc. 2018;19(4):287-295.e4.
140. Runzer-Colmenares FM, Urrunaga-Pastor D, Aguirre LG, Reategui-Rivera CM, Parodi JF, Taype-Rondan A. Frailty and vulnerability as predictors of radiotoxicity in older adults: A longitudinal study in Peru. Med Clínica. 2017;149(8):325–30.
141. Runzer-Colmenares FM, Samper-Ternent R, Al Snih S, Ottenbacher KJ, Parodi JF, Wong R. Prevalence and factors associated with frailty among Peruvian older adults. Arch Gerontol Geriatr. 2014;58(1):69–73.
142. Curcio C-L, Henao G-M, Gomez F. Frailty among rural elderly adults. BMC Geriatr. 2014;14(1):2.
143. Ocampo-Chaparro JM, de J. Zapata-Ossa H, Cubides-Munévar ÁM, Curcio CL, Villegas JDD, et al. Prevalence of poor self-rated health and associated risk factors among older adults in Cali, Colombia. Prevalencia de factores de riesgo de la autopercepción de salud y asociados pobres entre los adultos mayores en Cali, Colombia. Colomb. Med. 2013;44(4):224–31.
144. Ramírez Ramírez JU, Cadena Sanabria MO, Ochoa ME. Aplicación de la Escala de fragilidad de Edmonton en población colombiana. Comparación con los criterios de Fried. Rev Esp Geriatr Gerontol. 2017;52(6):322–5.
145. Samper-Ternent R, Reyes-Ortiz C, Ottenbacher KJ, Cano CA. Frailty and sarcopenia in Bogotá: results from the SABE Bogotá Study. Aging Clin Exp Res. 2017;29(2):265–72.
146. Del Brutto OH, Mera RM, Brown DL, Nieves JL, Milla-Martinez MF, Fanning KD, et al. The association of frailty with abnormal ankle-brachial index determinations is related to age: Results from the Atahualpa Project. Int J Cardiol. 2016;202:366–7.
147. Del Brutto OH, Mera RM, Cagino K, Fanning KD, Milla-Martinez MF, Nieves JL, et al. Neuroimaging signatures of frailty: A population-based study in community-dwelling older adults (the Atahualpa Project). Geriatr Gerontol Int. 2017;17(2):270–6.
148. Costa D, Aladio M, Girado CA, Pérez de la Hoz R, Sara Berensztein C. Frailty is independently associated with 1-year mortality after hospitalization for acute heart failure. IJC Hear Vasc. 2018;21:103–6.
149. Siriwardhana DD, Hardoon S, Rait G, Weerasinghe MC, Walters KR. Prevalence of frailty and prefrailty among community-dwelling older adults in low-income and middle-income countries: a systematic review and meta-analysis. BMJ Open. 2018;8(3):e018195.
150. Banks LM, Kuper H, Polack S. Poverty and disability in low- and middle-income countries: A systematic review. PLoS One. 2017;12(12):e0189996.
151. Singer L, Green M, Rowe F, Ben-Shlomo Y, Morrissey K. Social determinants of multimorbidity and multiple functional limitations among the ageing population of England, 2002-2015. SSM Popul Health. 2019;8:100413.
152. Buttery AK, Busch MA, Gaertner B, Scheidt-Nave C, Fuchs J. Prevalence and correlates of frailty among older adults: findings from the German health interview and examination survey. BMC Geriatr. 2015;15:22.
153. Chao C-T, Wang J, Chien K-L, group Co of GeN in N (COGENT) study. Both pre-frailty and frailty increase healthcare utilization and adverse health outcomes in patients with type 2 diabetes mellitus. Cardiovasc Diabetol. 2018;17(1):130.
154. Tom SE, Adachi JD, Anderson FA, Boonen S, Chapurlat RD, Compston JE, et al. Frailty and fracture, disability, and falls: a multiple country study from the global longitudinal study of osteoporosis in women. J Am Geriatr Soc. 2013;61(3):327–34.
155. Yu R, Morley JE, Kwok T, Leung J, Cheung O, Woo J. The Effects of Combinations of Cognitive Impairment and Pre-frailty on Adverse Outcomes from a Prospective Community-Based Cohort Study of Older Chinese People. Front Med. 2018;5:50.
156. Vieira ER, Da Silva RA, Severi MT, Barbosa AC, Amick Iii BC, Zevallos JC, et al. Balance and Gait of Frail, Pre-Frail, and Robust Older Hispanics. Geriatrics. 2018;3(3):42.
157. Muscedere J, Waters B, Varambally A, Bagshaw SM, Boyd JG, Maslove D, et al. The impact of frailty on intensive care unit outcomes: a systematic review and meta-analysis. Intensive Care Med. 2017;43(8):1105–22.
158. Bernabeu-Mora R, García-Guillamón G, Valera-Novella E, Giménez-Giménez LM, Escolar-Reina P, Medina-Mirapeix F. Frailty is a predictive factor of readmission within 90 days ofhospitalization for acute exacerbations of chronic obstructive pulmonarydisease: a longitudinal study. Ther Adv Respir Dis. 2017;11(10):383.
159. Kojima G. Frailty as a Predictor of Nursing Home Placement Among Community-Dwelling Older Adults. J Geriatr Phys Ther. 2018;41(1):42–8.
160. Kojima G. Frailty as a predictor of disabilities among community-dwelling older people: a systematic review and meta-analysis. Disabil Rehabil. 2017;39(19):1897–908.
161. Cesari M, Marzetti E, Thiem U, Pérez-Zepeda MU, Abellan Van Kan G, Landi F, et al. The geriatric management of frailty as paradigm of “The end of the disease era”. Eur J Intern Med. 2016;31:11–4.
162. Lopez P, Pinto RS, Radaelli R, Rech A, Grazioli R, Izquierdo M, et al. Benefits of resistance training in physically frail elderly: a systematic review. Aging Clin Exp Res. 2018;30:889–99.
163. Fiatarone MA, Marks EC, Ryan ND, Meredith CN, Lipsitz LA, Evans WJ. High-Intensity Strength Training in Nonagenarians. JAMA. 1990;263(22):3029.
164. Coelho-Júnior HJ, Rodrigues B, Uchida M, Marzetti E. Low Protein Intake Is Associated with Frailty in Older Adults: A Systematic Review and Meta-Analysis of Observational Studies. Nutrients. 2018;10(9):1334.
165. Coelho-Júnior HJ, Calvani R, Picca A, Gonçalves IO, Landi F, Bernabei R, et al. Protein-related dietary parameters and frailty status in older community-dwellers across different frailty instruments. Nutrients. 2020;12(2):508.
166. Calvani R, Miccheli A, Landi F, Bossola M, Cesari M, Leeuwenburgh C, et al. Current nutritional recommendations and novel dietary strategies to manage sarcopenia. J Frailty Aging. 2013;2(1):38–53.
167. Cadore EL, Sáez de Asteasu ML, Izquierdo M. Multicomponent exercise and the hallmarks of frailty: Considerations on cognitive impairment and acute hospitalization. Exp Gerontol. 2019;122:10–4.
168. Rodriguez-Larrad A, Arrieta H, Rezola C, Kortajarena M, Yanguas JJ, Iturburu M, et al. Effectiveness of a multicomponent exercise program in the attenuation of frailty in long-term nursing home residents: Study protocol for a randomized clinical controlled trial. BMC Geriatr. 2017;17(1):60.
169. Tarazona-Santabalbina FJ, Gómez-Cabrera MC, Pérez-Ros P, Martínez-Arnau FM, Cabo H, Tsaparas K, et al. A Multicomponent Exercise Intervention that Reverses Frailty and Improves Cognition, Emotion, and Social Networking in the Community-Dwelling Frail Elderly: A Randomized Clinical Trial. J Am Med Dir Assoc. 2016;17(5):426–33.
170. Tabue-Teguo M, Dartigues J-F, Simo N, Kuate-Tegueu C, Vellas B, Cesari M. Physical status and frailty index in nursing home residents: Results from the INCUR study. Arch Gerontol Geriatr. 2018;74:72–6.
171. Zhang XM, Dou QL, Zhang WW, Wang CH, Xie XH, Yang YZ, et al. Frailty as a Predictor of All-Cause Mortality Among Older Nursing Home Residents: A Systematic Review and Meta-analysis. J Am Med Dir Assoc. 2019;30:657-663.e4.
172. Lin SM, Aliberti MJR, Fortes-Filho S de Q, Melo JA, Aprahamian I, Suemoto CK, et al. Comparison of 3 Frailty Instruments in a Geriatric Acute Care Setting in a Low-Middle Income Country. J Am Med Dir Assoc. 2018;19(4):310-314.e3.
173. Åhlund K, Ekerstad N, Öberg B, Bäck M. Physical Performance Impairments and Limitations among Hospitalized Frail Older Adults. J Geriatr Phys Ther. 2018;41(4):230–5.