Introduction

There is a remarkable increase in aging worldwide, and Peru is not the exception. According to the Instituto Nacional de Estadística e Informática (INEI, National Institute of Statistics and Data Processing) data, there are demographic changes, which showed that the population rate was 5.7 % in 1950 and rose to 13.3 % in 2022 ¹. Frailty—along with sarcopenia—is considered a new and remarkable giant syndrome of geriatrics. In this case, the person is in a vulnerable state and at risk of morbidity or mortality when facing a health problem ². Frailty itself increases the risk of institutional confinement, falls, disability and cognitive impairment ³. There are two accepted trends to define and measure frailty. The frailty phenotype model identified by Fried et al. ³ with five components (weight loss, poor endurance, weakness, slow gait speed and low physical activity) was the first, and it referred to physical frailty. Later, a second model of deficit accumulation was created: when the number of adverse health conditions is higher, a value or frailty index (FI) is generated in a multidimensional scale that focusses not only on the physical-motor aspect, which results in a wider definition ⁴. In "Frailty Consensus" of 2013, carried out by a group of experts and international associations, frailty was defined as a syndrome with multiple causes that contribute to reduce strength as well as the physiological function, thus exposing the individual to the risk of dependency and/or mortality ⁵.

The prevalence of frailty varies worldwide, depending on the studied population and the tool used to detect it. Research studies have started in Peru in order to determine an approximate prevalence. A study conducted among older adults with heart failure at a hospital in Lima revealed a prevalence of 58.8 % by means of the Edmonton Frail Scale ^6,7. Another research carried out in Lima at the hospital level using the FRAIL scale was associated with frailty among people over 80 years old, cognitive impairment, depression and malnutrition ⁸. A study conducted in Chiclayo showed 17.5 % of patients with this syndrome using the definition "Women’s Health and Aging Studies." Another study carried out in the same city among patients of the first healthcare level, which used Fried’s criteria, found a prevalence of 20.7 % ⁹.

Another study on the frequency and associated factors was conducted using frailty phenotype in Lambayeque, and a prevalence of 22.78 % was found, the related factors being age, arthropathies and vision problems ¹⁰. A prevalence study among outpatients over 60 years old was carried out in Trujillo using the Fried phenotype, and 59.29 % was found ¹¹. It should be mentioned that these studies neither used scales measuring the FI nor calculated mortality as a result. In the FI, the risk of death exponentially increases according to deficit accumulation that has adverse health effects. Also, the scales used are multidimensional and share the approach of the Comprehensive Geriatric Assessment (CGA). Frailty Index-CGA (FI-CGA) is an easy-to-use scale (it takes less than 10 minutes), where variables are taken from a classic CGA comprising 22 general questions for 25 deficits. The FI is obtained dividing the deficits found (considering one point for each) by the potential ones. If the FI is equal to or greater than 0.2, the score corresponds to frail population. From this point, it is divided into three groups: mildly frail (FI 0.2-0.36), moderately frail (FI 0.4-0.52) and severely frailty (FI over 0.56) ¹². There is an excellent correlation between FI-CGI and mortality, which reduces the bias of age and highlights the importance of deficit accumulation. Also, it can identify the stage of the biological pathway determining the patient’s approximate physiological reserve ¹³. Though there are research studies on this topic in different regions of the country, there is no information about the prediction of mortality associated with the degree of frailty or the use of tools that research the concept of frailty on a multidimensional basis and provide a value or index to define it.

Materials and methods

Results

A total of 241 subjects with a mean age of 85.08 years (61-105 years) were included. The percentage of females was 65.97 %. Out of the evaluated sample, 53.53 % had a Barthel Index greater than or equal to 65 points, 87.14 % had some degree of cognitive impairment, 34.02 % had delirium in the last six months, 80.08 % had polypharmacy and 22.82 % had falls in the last six months. In addition, a high prevalence of chronic diseases stands out: 59.33 % suffered from a neurological disease, 48.54 % a renal disease, 47.71 % a cardiovascular disease and 26.97 % a respiratory disease. Moreover, 14.51 % of the patients met the advanced chronicity criteria according to NECPAL.

Only 7.88 % (n = 19) of the of the population analyzed according to the FI-CGA had a FI < 0.2, and it should be noted that 92.12 % (n = 222) of the patients were frail (FI ≥ 0.2). Out of the group of frail patients, 34.02 % (n = 82) were mildly frail, 26.14 % (n = 63) moderately frail and 31.96 % (n = 77), severely frail (Figure 1).

Figure 1 FI-CGA and mortality at a 12-month follow-up 

The follow-up finished with death as an adverse event or it was carried out up to 12 months after the first evaluation. After a year, a mortality rate of 11.61 % (n = 28) was found. Out of the 28 deceased, 82.14 % (n = 23) showed severe frailty (FI ≥ 0.56).

When analyzing the association between mortality and the FI-CGA, it was found that the higher the FI, the higher the mortality, with very significant differences (p = 0.001). There was no association between age and mortality (p = 0.95).

Discussion

Due to population aging, there are various research studies that use deficit accumulation models worldwide resulting in a FI ^17,18.

The mean age of the studied population was 85 years, which differs from other research studies conducted in Peru, where the mean was under 80 years ^7-9.

The prevalence of frailty using the FI-CGA was high: 92.12 % of the studied population. This value is very different from those found by other studies conducted in our setting, which had a prevalence of frailty of 7.70 % in the community ¹⁹, 22.78 % in two hospitals in the north of the country ⁹ and 20.00 % at a first level of healthcare ²⁰. Although there is evidence of a large gap between the prevalence found in this study compared to others, it should be mentioned that they used the physical frailty phenotype proposed by Fried to detect frailty ²¹. The prevalence of frailty shown by the sample of this research was high, and it was attributed to two reasons: frailty measured by our study was multidimensional, not only physical but also cognitive and social; in addition, our sample corresponds to an area specialized in treating vulnerable older people ^22,23. Both reasons explain the increase in our percentage.

When evaluating the functionality of the Barthel scale, a little more than a half had mild dependence, which was similar to other studies ^10,19. Concerning polypharmacy, 80 % of the studied population showed such condition, which was higher than that found in other frailty studies conducted in Peru ²⁴.

Age did not influence mortality significantly in this study, as Amblàs-Novellas et al. demonstrated ^12,13, which reflected that biological age and physiological reserve should be given more importance.

In addition, it should be mentioned that the FI-CGA showed excellent correlation with mortality, as prior studies showed ^25-27.

The predictive ability of the instrument for this cohort was also previously described by other frailty indices ^28,29.

That fact became evident after the SARS-CoV-2 pandemic, when the health of older adults was compromised, and this is an important factor of higher frailty. Our healthcare center is a place where patients are referred to for diagnosis/management of more complex cases that occur in older adults, this being the reason that could explain the high percentage of frail patients in our sample. The described cohort is not representative of general population; therefore, new studies should be carried out to confirm data described in less elderly populations with lower percentage of advanced chronicity as well as in other healthcare levels. Despite there is not a gold standard

definition of frailty, and it complicates the use of current instruments, the indices allow not only to diagnose but also to predict the risk of adverse events, even death ³⁰.

In conclusion, the higher the frailty index, the higher the mortality at a 12-month follow-up. The FI-CGA is a simple and useful tool to predict mortality after a 12-month follow-up among older adults.