Association Between Functionality, Depressive Symptoms, and Fragility in Elderly Adults in Primary Care

Abstract

As life expectancy increases, the disease profile of the population also changes, with a higher prevalence of chronic diseases and reduced functional capacity, which increases the risk of social isolation and vulnerability. The aim of this study was to identify the association between functionality, depressive symptoms, and fragility in elderly adults in primary care. This is an exploratory, descriptive study with a quantitative approach and a cross-sectional design, carried out in a municipality in the interior of southwestern Bahia. The instruments used were the Mini-Mental State Examination (MMSE), a sociodemographic questionnaire on health conditions, the Edmonton Fragility Scale (EFS), and the Self-Reported Fragility Scale. The data were analyzed through descriptive analyses with absolute and relative frequencies and the application of the Chi-square test, adopting a value of p ≤ 0.05. Results: A statistically significant difference was found between elderly adults classified as frail and female gender (p = 0.019), marital status without a partner (p = 0.001), dependence in BADL (p = 0.008), dependence in IADL (p-value = 0.000), and the presence of depressive symptoms (p = 0.000). Conclusion: This study found an association between marital fragility related to being without a partner, dependence in IADL (instrumental activities of daily living), and the presence of depressive symptoms.

1. Introduction

Aging is a physiological and irreversible process that takes place progressively and involves changes in all the body’s systems. These changes, when associated with pathological processes, can impact the performance of basic activities of daily living (BADLs) and instrumental activities of daily living (IADL), resulting in a poor quality of life for older people [1,2].

As life expectancy increases, the population’s disease profile also changes, with a higher prevalence of chronic diseases and reduced functional capacity, which increases the risk of social isolation and vulnerability. From this perspective, the increasing number of very old people is a concern for public health, considering the rise in the incidence of fragility and functional dependence among the elderly, which considerably increases healthcare costs [3].

In addition to the chronic diseases commonly associated with aging, such as hypertension, diabetes, osteoarthritis, osteoporosis, and heart disease, there is also the emergence of geriatric syndromes: cognitive incapacity, communicative incapacity, postural instability, sphincteric incontinence, iatrogenic, immobility, and family insufficiency. In addition to these main syndromes, which compromise both the physical and psychological health of the elderly, there is also a high incidence of fragility syndrome [3]. In this study, we adopt the concept of fragility as a state of exaggerated vulnerability arising from a combination of several factors, making the individual more susceptible to adverse health outcomes such as falls, disability, hospitalization, and death [4].

Described as a clinical condition that creates greater vulnerability to disease and biological stress for the elderly, fragility can be identified by the criteria described as follows [4]: involuntary weight loss, exhaustion, reduced walking speed, reduced grip strength, and reduced physical activity. The pathophysiology of fragility is related to a reduction in the body’s functional reserve and alterations in the neuroendocrine system [4].

Both impaired functionality, fragility, and depression, individually or together, can have substantial impacts on the health and quality of life of older adults, especially older adults in primary care who tend to have worse health indicators compared to older adults served by private health insurance plans. Therefore, it is important to analyze the association between these conditions to contribute to the literature on the subject, as well as to discuss their potential impacts, thus providing more information so that preventive and treatment measures can be adopted. In this way, we hope to contribute to promoting more active aging with a better quality of life.

This study aims to identify the association between functionality, depressive symptoms, and fragility in elderly adults in primary care.

2. Materials and Methods

This is a descriptive and exploratory study with a cross-sectional design and quantitative approach, carried out in a Family Health Unit (USF) in the interior of Bahia. This health unit was chosen because it is located near the State University of Southwest Bahia, which facilitated the research team’s travel for data collection. It was also chosen because it serves as a field for internships for health-related courses and for the university’s research and outreach projects.

The sample consisted of 143 elderly people. Of the 158 elderly adults registered at the health unit chosen for the study, 7 could not be located, 3 died, and 5 were excluded from the study after 3 attempts to schedule a visit. Data collection took place from July 2022 to May 2024. The data were collected by undergraduate and graduate students previously trained by the researchers involved in the study. The research instrument was administered after the elderly person signed the Informed Consent Form.

All individuals aged 60 or older, of both sexes, registered at the two health units were selected to participate in the study. Individuals who could not be located at their homes after three attempts, or those who, at the time of the interview, did not have an adequate informant present if they were unable to understand the instructions due to cognitive impairment, were excluded from the research. Cognitive screening was performed with the elderly using the Mini-Mental State Examination (MMSE) by Folstein; Folstein; McHugh, 1975, with the version used in Brazil and adapted by Bertolucci et al. [5], with a score of 17 or less representing unsatisfactory cognitive conditions. It should be noted that MMSE was used only as a tracking tool.

In this context, the use of the instrument allowed the screening of individuals with severe cognitive decline to minimize the bias that could be caused by the low educational level of the respondents.

The research instrument consisted of the following: Sociodemographic and Health Conditions Questionnaire (self-reported data), Edmonton Fragility Scale (EFS), and the Self-Reported Fragility Scale.

The Sociodemographic and Health Conditions Questionnaire assessed age, gender (female and male), schooling, family income, marital status, chronic diseases, and medication use.

Functionality was assessed using the Barthel Scale [1,3] and the Lawton and Body Scale [1,3]. The Barthel Scale assesses basic activities of daily living (feeding, bathing, dressing, personal hygiene, urination, defecation, toilet use, bed/chair transfer, ambulation, and stairs), with scores ranging from 0 to 100, where independence: 100 points; mild dependence: 60–95; moderate dependence: 40–55; severe dependence: 20–35; total dependence: less than 20 [1,3].

The Lawton and Body Scale assesses instrumental activities of daily living (using the telephone, traveling, shopping, preparing meals, housework, medication use, and finances). Its score ranges from 0 to 21, where total dependence: less than or equal to 5; partial dependence: greater than 5 and less than 21; independent = 21 [1,3].

To assess depressive symptoms, the Geriatric Depression Scale was used. It evaluates the risk of depression in older adults through 15 questions that measure life satisfaction and interest in daily activities. The score ranges from 0 to 15, with no depression: less than 5; mild depression: 5 to 10; severe depression: greater than 10 [2].

The Edmonton Fragility Scale (EFS) assesses the following nine domains: cognition, general health status, functional independence, social support, medication use, nutrition, mood, continence, and functional performance. Individuals with scores between zero and four are considered not frail, those between five and six are apparently vulnerable, those between seven and eight are mildly frail, those between nine and ten are moderately frail, and those eleven and over are severely frail [6,7].

The Self-Reported Fragility Scale was constructed based on participants’ subjective perception of their fragility status. This instrument assesses aspects such as general health, physical functionality, ability to perform daily activities, and symptoms associated with fragility (e.g., fatigue, weight loss). The sum of the response scores was used to create the continuous variable of the fragility index [6,7].

The data were analyzed using SPSS version 21.0. In this program, descriptive analyses with absolute and relative frequencies were performed, and the Chi-square test was applied with a value of p ≤ 0.05. The project was approved by the Research Ethics Committee of the Faculdade Independente do Nordeste under Protocol No. 4.351.219. To take part in the study, the elderly adult signed an informed consent form.

3. Results

There was a higher frequency of elderly women (67.1%), with a partner (52.4%), literate (93.0%), aged between 80 and 88 (57.3%), and with an income of up to one (1) minimum wage (59.5%). The average age was 71.05 years. There was a greater distribution of elderly adults with chronic diseases (86.7%), pain (80.4%), and controlled medication use (74.8%) (Table 1).

Table 1. Distribution of elderly adults according to sociodemographic profile and health conditions.

	n	%
Gender
Female	96	67.1
Male	47	32.9
Marital status
With partner	75	52.4
Without partner	68	4.6
Education
No schooling	133	93.0
With schooling	10	7.0
Age group
60 to 68 years old	82	57.3
69 or over	61	42.7
Income
Up to 1 minimum wage	85	59.5
Above 1 minimum wage	58	40.5
Health problem
Yes	124	86.7
No	19	13.3
Presence of pain
Yes	115	80.4
No	28	19.6
Uses controlled medication
Yes	107	74.8
No	36	25.2

When assessing fragility, there was a higher frequency of elderly adults who were not frail (68.5%). As for self-reported fragility, there was a higher distribution of elderly adults with pre-fragility (44.1%) (Table 2).

Table 2. Distribution of elderly adults according to the fragility variable.

	n	%
Edmonton Fragility Scale (EFS)
No fragility (0–4 points)	98	68.5
Apparently vulnerable (5–6 points)	21	14.7
Mild fragility (7–8 points)	17	11.9
Moderate fragility (9–10 points)	6	4.2
Severe fragility (11 points or more)	1	0.7
Self-reported fragility
Presence of fragility (≥3 criteria)	58	40.6
Pre-fragility (1 or 2 criteria)	63	44.1
No fragility (0 criterion)	22	15.4

Applying the Chi-square test between the study variables and the Edmonton Fragility Scale, a statistically significant difference was found between the elderly adults classified as frail and the variables of female gender (p = 0.019), marital status without a partner (p = 0.001), dependence in BADL (p = 0.008), dependence in IADL (p = 0.000), and the presence of depressive symptoms (p = 0.000), as shown in Table 3.

Table 3. Distribution of the Chi-square test.

Fragility [Edmonton Fragility Scale (EFS)]
	No Fragility		Fragility		Total		Value of p
	n	%	n	%	n	%
Gender
Female	86	89.6	10	10.4	96		0.019
Male	35	74.5	12	25.5	47
Marital status
Without partner	20	87.0	3	13.0	23		0.001 *
With partner	101	84.2	19	15.8	120
Education
No schooling	6	75.0	2	25.0	8		0.124
With schooling	112	86.2	18	13.8	130
Age group
60 to 68 years old	67	81.7	15	18.3	82		0.189
69 years old or older	54	88.5	7	11.5	61
BADL
Independent	99	83.9	19	16.1	118		0.008
Dependent	22	88.0	3	12.0	25
IADL
Dependent	120	84.5	22	15.5	142		0.000 *
Independent	1	100.0	-	-	1
Depressive symptoms
No depressive symptoms	101	84.2	19	15.8	120		0.001 *
With depressive symptoms	20	87.0	3	13.0	23

BADL = basic activities of daily living. IADL = instrumental activities of daily living. * statistically significant difference.

4. Discussion

The results of this study showed that some sociodemographic characteristics and health conditions are significantly associated with the presence of fragility among the elderly adults assessed. Among the factors analyzed, an association was found with gender, marital status, level of independence in BADLs and IADL, and the presence of depressive symptoms.

There was a higher proportion of fragility among men compared to women, with a statistically significant association. This finding differs from the majority of studies available in the literature, which often indicate a higher prevalence of fragility among women [6,7,8]. This result can be attributed to lifestyle factors, lower adherence to preventive care, and lower use of health services among men [9].

Although most studies indicate an association between a higher risk of fragility and being female, there have also been findings similar to the results of this research, such as a study that assessed the fragility of institutionalized elderly adults from two Long-Stay Institutions for the Elderly (ILPI) in Pindamonhangaba/SP, which found a predominance of fragility in males (61.9%) [10].

Marital status was also significantly associated with fragility. Elderly adults with a partner had a higher risk of fragility than those without. This result contradicts some of the literature, which generally associates marital life with greater social support and protection against vulnerability [11,12,13]. A possible explanation for this difference may be related to the type of relationship established, the burden of caring for sick partners, or specific characteristics of the sample studied.

Despite the scarcity of evidence corroborating this finding, a study conducted with elderly adults living in the community and accompanied by community health agents (ACSs) from a Basic Health Unit (UBS) in the municipality of Guarapuava, investigated the association between family functionality and fragility among the variables analyzed. The results indicated that although family functionality was considered favorable, it was not enough to minimize the conditions that contributed to the development of fragility [14].

As for functionality, there was a significant association between fragility and dependence in activities of daily living. In relation to ADLs, dependent older people had a slightly lower proportion of fragility than independent people. As for IADL, dependence was clearly associated with fragility. These findings reinforce the relationship between loss of functionality and the development of fragility, as highlighted by studies which point to functional decline as one of the main clinical manifestations of fragility [11,15,16]

Early identification of this association in primary care is fundamental to preventing the loss of autonomy and independence in older adults. Primary care is the preferred entry point to the health system and an ideal environment for screening, managing, and preventing these conditions. Research provides essential data for planning actions and implementing comprehensive and personalized care, such as promoting physical activity and improving social support.

A longitudinal study using the database of the Health, Well-Being, and Aging Study (SABE) in 2006 and 2010 concluded that the prevalence of fragility among non-institutionalized elderly adults was associated with functional impairment [17]. Another study carried out with elderly adults living in urban areas in the city of Uberaba, MG, showed that the higher the level of fragility, the higher the level of dependency in the elderly [18]. These results show the significant impact of functional disabilities on the lives of elderly people, directly contributing to the development and worsening of fragility.

In addition, the presence of depressive symptoms was also statistically associated with fragility. Although the percentage difference between the groups with and without depressive symptoms was not significant, the data suggest that psychological aspects play an important role in the process of fragility. The literature corroborates these findings by repeatedly indicating that depressive symptoms are strongly associated with a higher risk of fragility in older people [10,11,12,13,14,15,16,17,18,19].

A cross-sectional and longitudinal study conducted over five years with data from the SABE study assessed the prevalence of fragility and its association with depressive symptoms among elderly Europeans from 17 countries, indicating that frail participants were more likely to have depressive symptoms over time [19]. Similarly, a cross-sectional study of elderly adults over 60 living in four Brazilian long-term care institutions for the elderly in the city of Rio de Janeiro found that frail elderly adults were 2.8 times more likely to have depressive symptoms than pre-frail people [20].

The cross-sectional design of this study, with only one measurement point, is a limitation, since the direction of the causal relationship between fragility, functionality, and depressive symptoms cannot be determined, as this association may also be bidirectional. Another point to highlight is that the elderly adults excluded from the sample were possibly much more frail and had greater impairments in functional and cognitive capacity than those included in the study. Furthermore, the sample size may not have been statistically sufficient to fully analyze these associations, which could explain why some results were not consistent with previous literature.

The data reported here can be used to plan actions and strategies that promote the health of this population, which is already weakened by aging and low education levels, among other unfavorable factors.

5. Conclusions

The results of this study show a significant association between functionality, depressive symptoms, and the presence of fragility in elderly people. In addition to these variables, others such as female gender and marital status without a partner also showed a statistically significant association with fragility, indicating the need for a broader, multidimensional approach to assessing this population. These findings reinforce the understanding that fragility is not an inevitable process of aging, but rather a potentially predictable condition that can be intervened upon. Therefore, it is necessary for primary healthcare teams to invest in preventive actions and interventions aimed at these determinants, which can reduce the prevalence of fragility and, consequently, improve the quality of life and functionality of this population.