0345/2024 - Prevalencia y factores asociados a fragilidad en ancianos residentes en el área urbana: Casino Deportivo, 2020
Prevalência e fatores associados à fragilidade em idosos residentes em áreas urbanas: Casino Deportivo, 2020
Autor:
• Daniel Munyambu Mutonga - Mutonga, D.M - <danielmutonga@gmail.com>ORCID: https://orcid.org/0000-0003-2846-5953
Coautor(es):
• Maria Carla Lapadula - Lapadula, M.C - <carla.lapadula@utoronto.ca>ORCID: https://orcid.org/0000-0001-5156-121X
• Bárbara Meylin González Martínez - Martínez, B.M.G - <babyglezmtnez@gmail.com>
ORCID: https://orcid.org/0009-0006-9608-9434
• Yaima Álvarez Rodríguez - Rodríguez, Y.A - <yaima.alvarez@infomed.sld.cu>
ORCID: https://orcid.org/0000-0002-3877-2378
Resumo:
Introducción: Los adultos mayores (AAMM) frágiles tienen un mayor riesgo de caídas, discapacidad, dependencia, hospitalización y muerte.Objetivo: Determinar la prevalencia más actualizada de fragilidad en los ancianos y caracterizar los factores relacionados con la fragilidad.
Métodos: Se realizó un estudio de diseño transversal, seleccionado aleatoriamente AAMM registrados en la historia de salud familiar del CMF No 17, “Antonio Maceo”. Utilizando la escala geriátrica de evaluación funcional registrada y los criterios cubanos de fragilidad, se evaluaron asociaciones mediante Chi-cuadrado y regresión binaria múltiple utilizando el programa SPSS versión 27.
Resultados: Se estudiaron 128 ancianos quienes fueron principalmente mujeres (64,1%), ancianos entre 60 y 69 años (40,6%), de piel blanca (84,4%), con formación universitaria (31,3%), jubilados (48,4%) y con predominio el Grupo III (77.3%). Reportamos una prevalencia de fragilidad de 5,1% que se asoció con la edad, el color de piel, el nivel de educación y el grupo de dispensarización.
Conclusiones: Hubo una baja tasa de prevalencia de fragilidad. Estos hallazgos podrían reflejar una mejora en el cuidado de los AAMM, mientras que predictores de fragilidad identificados podrían ayudar en la atención específica.
Palavras-chave:
ancianos, envejecimiento, fragilidad, escala geriátrica de evaluación funcionalAbstract:
Introdução: A fragilidade em idosos leva a quedas, incapacidade, dependência, hospitalização e morte.Objetivo: Determinar a prevalência mais atualizada de fragilidade entre adultos mais velhos e caracterizar os factores relacionadas à fragilidade.
Métodos: Foi realizado um estudo de desenho transversal, selecionando aleatoriamente adultos com mais de 60 anos registrados no histórico de saúde familiar do CMF Nº 17, \"Antonio Maceo\". O estado de fragilidade foi determinado por meio da avaliação funcional geriátrica registrada e dos critérios cubanos de fragilidade. O análise estatístico avaliou múltiplas associações utilizando Chi-Sqate e regressão binária múltipla utilizando o programa SPSS versão 27.
Resultados: A maioria dos 128 idosos recrutados era do sexo feminino (64,1%), com idade entre 60 e 69 anos (40,6%), de pele branca (84,4%), com formação universitária (31,3%), aposentados (48,4%) principalmente do Grupo III (77,3%). Relatamos uma prevalência de fragilidade de 5,1% que foi associada à idade avançada, cor da pele, escolaridade e grupo de \"dispensarização\".
Conclusões: Houve uma baixa taxa de prevalência de fragilidade. Os resultados do estudo podem refletir melhorias no cuidado de idosos e os correlatos de fragilidade podem ser úteis na prevenção, triagem e tratamento direcionados.
Keywords:
idoso, envelhecimento, fragilidade, geriatria, avaliação funcionalConteúdo:
Acessar Revista no ScieloOutros idiomas:
Prevalência e fatores associados à fragilidade em idosos residentes em áreas urbanas: Casino Deportivo, 2020
Resumo (abstract):
Introdução: A fragilidade em idosos leva a quedas, incapacidade, dependência, hospitalização e morte. Objetivo: Determinar a prevalência mais atualizada de fragilidade entre adultos mais velhos e caracterizar os factores relacionadas à fragilidade. Métodos: Foi realizado um estudo de desenho transversal, selecionando aleatoriamente adultos com mais de 60 anos registrados no histórico de saúde familiar do CMF Nº 17, \"Antonio Maceo\". O estado de fragilidade foi determinado por meio da avaliação funcional geriátrica registrada e dos critérios cubanos de fragilidade. O análise estatístico avaliou múltiplas associações utilizando Chi-Sqate e regressão binária múltipla utilizando o programa SPSS versão 27. Resultados: A maioria dos 128 idosos recrutados era do sexo feminino (64,1%), com idade entre 60 e 69 anos (40,6%), de pele branca (84,4%), com formação universitária (31,3%), aposentados (48,4%) principalmente do Grupo III (77,3%). Relatamos uma prevalência de fragilidade de 5,1% que foi associada à idade avançada, cor da pele, escolaridade e grupo de \"dispensarização\". Conclusões: Houve uma baixa taxa de prevalência de fragilidade. Os resultados do estudo podem refletir melhorias no cuidado de idosos e os correlatos de fragilidade podem ser úteis na prevenção, triagem e tratamento direcionados.Palavras-chave (keywords):
idoso, envelhecimento, fragilidade, geriatria, avaliação funcionalLer versão inglês (english version)
Conteúdo (article):
Prevalence and factors associated with frailty among elderly residents in urban area: Casino Deportivo, 2020Autor: 1,2 Daniel Munyambu Mutonga – Mutonga, D. M. - residente keniano en Primer grado de Medicina General Integral y Máster en Enfermedades Tropicales e Infecciosas
1 Facultad de Ciencias Médicas “Salvador Allende”, Universidad de Ciencias Médicas de La Habana, Cerro, La Habana, Cuba.
2 Mathari National Teaching and Referral Hospital, Nairobi, Kenia.
< danielmutonga@gmail.com >
ORCID: https://orcid.org/0000-0003-2846-5953
Correspondencia: Dirección postal: P. O. Box 11692 – 00100 Nairobi, Kenia. Teléfono: +254 702 799 221. Correo electrónico: danielmutonga@gmail.com
Coautor(es):
3 Maria Carla Lapadula – Lapadula, M. C. - especialista en Medicina General, Familiar y comunitaria e Investigadora Asociada
3 Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Canada.
< carla.lapadula@utoronto.ca >
ORCID: https://orcid.org/0000-0001-5156-121X
4 Bárbara Meylin González Martínez – Martínez, B. M. G. - especialista en Primer grado de Medicina General Integral
4 Policlínico Docente “Antonio Maceo”, Cerro, La Habana, Cuba.
< gonzalez9005.ferrer@gmail.com >
ORCID: https://orcid.org/0009-0006-9608-9434
4 Yaima Álvarez Rodríguez – Rodríguez, Y. A. - especialista en Primer grado de Medicina General Integral, Profesora Asistente y Máster en Enfermedades Infecciosas
4 Policlínico Docente “Antonio Maceo”, Cerro, La Habana, Cuba.
ORCID: https://orcid.org/0000-0002-3877-2378
ABSTRACT
Background: Frail older persons are prone to falls, disability, dependency, hospitalization and death.
Objective: To determine the most up-to-date prevalence of frailty among older adults (OA) and to characterize risk factors related to frailty.
Methods: A cross-sectional study recruiting participants from the family health records of CMF No 17, “Antonio Maceo” who were > 60 years and utilizing recorded functional assessment, calculating frailty status using the Cuban criteria of frailty and assessing for associations using Chi-Square and multiple binary regression on SPSS version 27.
Results: Most of the 128 participants were female (64.1%), aged between 60–69 years (40.6%), had white skin color (84.4%), were university graduates (31.3%), retired (48.4%) and had chronic illness (Group III, 77.3%). The prevalence of frailty status was 5.1% and was associated with older age, skin color, education level and “health status” group.
Conclusions: We observed a low frailty prevalence rate which may reflect improved elderly care. The findings on frailty risk factors may prove vital in prevention, screening and treatment.
Keywords: elderly, aging, frailty, geriatric, functional assessment
INTRODUCTION
Older adults (OA) form a critical group in society that possesses valuable experience, however, they are vulnerable and require special care. The elderly face challenges in terms of health, family relationships, social isolation and economic limitations due to reduced income 1. Frailty in the elderly is defined as a decreased physiological reserve and is associated with an increase in risks such as disability, dependency, falls, hospitalizations, institutionalizations and death 2,3. Globally, the prevalence of frailty in Spain ranges from 8.5–13.7%, while in Mexico it varies between 45–98% 4–6. There is a variable prevalence of frailty in Latin America with figures ranging from 4.5–19.3% in Chile and Peru respectively 7–10. In Brazilian studies, the prevalence of frailty ranged from 8.5–40.6% 9,11–13. These figures depend on the frailty measurement tool employed and the technique of sampling the study population.
Cuba is a developing Caribbean nation with a significant aging population similar to developed countries. With a life expectancy of 78.4 years, it is among the oldest countries in the world 1. In 2014, the proportion of the Cuban population which was elderly reached 19% and was projected to increase to 25% by 2025 14. In respect to Cuba, the prevalence of frailty ranges between 11.4–62.9% 2,3,8,15. Primary health care (PHC) in Cuba focuses on OA, promoting active aging through programs such as the National Comprehensive Care Program to the Elderly (PAM) which includes periodic health examination by the basic health team and comprehensive geriatric assessments by a multidisciplinary gerontological care team, taking place at institutional and hospital levels 16,17.
Previous studies have investigated the factors associated with frailty in the elderly. For example, in the Municipality of La Playa, Cuba and the Municipality of Macrorregión Triángulo Sur in Brazil, frailty was associated with advanced age, presence of comorbidities, high risk of metabolic complications, malnutrition, polypharmacy, smoking, education level, being single/divorced and having no children 12,13,18. Additionally, there were high rates of high blood pressure, ischemic heart disease, osteoarthritis, diabetes mellitus, bronchial asthma, chronic obstructive pulmonary disease (COPD), and neoplasms 12,18. Most of these earlier studies measured frailty using the 5 Fried\'s phenotype criteria. that defines the physical phenotype based on weight loss, low energy, slow mobility, muscle weakness, and low activity physics 4,6,19,20. Other frailty assessment tools include the Geriatric Functional Assessment Scale (EGEF), the Edmonton Frailty Scale, the FRAIL scale, the Barber Test, the Critical Frailty Scale or modified Rockwood, the Center for Research on Longevity, Aging and Health (CITED) Cuban criteria of frailty, and the frailty criteria of the Association of Combatants of the Cuban Revolution (ACRC) 15,21,22. Additional tools utilized in geriatric assessments include the nutritional assessment, quality of life (QoL), geriatric depression scale, cognitive assessment, the Katz index and the Lawton index 2,3,6,7,19.
There is currently little scientific evidence on frailty among the elderly, particularly in the area where this research was conducted 15,23. Secondly, this study is justified based on a previously high prevalence of frailty in Cuba, around 50%, compared to the rest of South America and the Caribbean 9,13,20. Thirdly, in addition to biological and clinical factors, this study investigates potential social determinants of frailty among the elderly, providing an opportunity to intervene at both the family and community level. The objective of this study was to determine the most recent prevalence of frailty among the elderly and characterize factors associated with frailty.
METHODS
Study design
An observational, cross-sectional, descriptive and analytical study was carried at the Family Doctor’s Clinic (CMF) No. 17 of the “Antonio Maceo” Polyclinic between April 1 and June 30, 2020. The first case of COVID-19 on 11 March 2020 on the island led to a lot of anxiety. However, thanks to political goodwill, well-designed and effectively implemented protocols, and trained health professionals; the impact of the pandemic was greatly reduced, and most deaths during this period were unrelated to COVID-19 1,24. Due to the pandemic and lockdown restrictions, we relied heavily on retrospective secondary data sources.
The study population
Havana province has the largest number of OA in Cuba whereas El Cerro – along with La Playa – are the third oldest municipalities in Havana with the proportion of OA at 21.9% 1,15,25. The “Antonio Maceo” teaching polyclinic has the largest aging population in the entire Cerro municipality occupying an area of 3,563 km2. According to the polyclinic\'s statistics, there were 8,007 OA during the study period. In respect to the “Casino Deportivo” health area belonging to the aforementioned polyclinic, there were 345 registered elderly persons (30.5%) out of a total of 1,132 residents and 420 families, according to 2018/2019 local statistics 7,13,20.
Sample size and sampling criteria
To determine the sample size, a formula for cross-sectional studies was used based on a 95% confidence level, a 5% margin of error, an expected proportion of 12%, an effect size of 1, and a non-response rate of 10% 7,13,20,26. A random sampling technique was used to select the desired sample from the universe list of all OA registered in the CMF No. 17. Our initial sample was 180 elderly people; however, we managed to review 128 records, representing a sample proportion of 71%. Using the online calculators OpenEpi and SampleSizeNet, sample size was determined to provide sufficient power for the study 27,28.
Selection criteria
Inclusion criteria: To be included in the study, participants had to be > 60 years, have an official residence in the study area, be registered in the family health records and have complete health records according to our study objectives.
Exclusion criteria: We excluded those with severe cognitive impairment, those unable to answer the questionnaire and without a caregiver, those in terminal phase of a disease, those permanently institutionalized and those absent from the area during the designated study period.
Data collection
Our initial goal was to conduct face-to-face interviews with all study participants and assess frailty status through a study-related geriatric assessment. However, due to the pandemic and lockdown restrictions, this procedure was abandoned in favor of collecting secondary data. We designed an appropriate abstraction questionnaire that included sociodemographic variables, biological, psychological, functional and social aspects in keeping with the EGEF.
Secondary data sources included family health history (HSF), family history individual clinic, and the EGEF. We randomly selected and reviewed the records of all study participants. The primary author conducted data collection. Using the Open Data Kit (ODK) application, the data collected in paper format were transferred to a database in Microsoft Excel 2020. OA were then classified as frail or non-frail using the EGEF and the Cuban criteria for frailty.
Study variables
Demographic characteristics: age attained in years (confirmed by informant and their identity card), sex at birth, skin color (white, mixed-race, black), education (none, incomplete primary, completed primary, completed secondary, intermediate technical, pre-university, university), marital status (single, legally married or cohabiting, divorced, widower), employment status, (housewife, retired, paid job, social security beneficiary social), economic situation (excellent, good, bad).
Biological characteristics: health status (I – supposedly healthy, II – with risk factors, III – chronic illness, IV – disabled), past medical history according to HSF (high blood pressure, diabetes mellitus, ischemic heart disease, bronchial asthma, COPD, cancer, heart failure, kidney failure, others), presence of disability (yes or no).
Social factors: Living alone or with others, housing structural conditions, overcrowding (yes > 3 people in a room, no < 3 people in a room), presence of caregiver (yes, no), type of caregiver (family member, paid employee), family functioning to the FF-SIL test and the HSF (functional, moderately functional, dysfunctional, severely dysfunctional), satisfaction with health services (yes, no).
Frailty: Frailty was diagnosed using the EGEF, a functional test designed for the elderly and allowing early detection of functional changes. In Cuba, frail OA run the risk of developing dependency due to their biological, psychological, social and functional status 15. The tool is composed by 13 variables including the global functional status (EFG), calculated from an average of the presiding 12 variables 29. Each of these variables represents a specific aspect, whether biological, psychological or social, with scores from 1–5. Biological aspects of the EGEF: continence, mobility, balance, vision, hearing, and medication use. Psychological aspects of the EGEF: sleep, emotional state, and memory disturbances. Social aspects of the EGEF: family situation, social situation, economic situation, and the EFG.
Additionally, a 10-point Cuban frailty criteria established by the CITED is used to determine frailty 3,15,21. The criteria include: double incontinence, impaired mobility, polypharmacy (use of > 3 medications), alteration of all variables, history of dementia, any combination of changes of social problems, lonely elderly, elderly person > 80 years any alteration, memory disorder, and EFG alteration (where an “alteration” is defined as < 3 in the EGEF).
Statistical Analysis
Analyses were performed using Microsoft Excel software® and the Statistical Package for Social Sciences (SPSS®) version 27. Variables were analyzed descriptively as absolute frequencies, proportions, measures of central tendency and dispersion. Results were summarized as tables and graphs. To determine the association between frailty and bio-psychosocial characteristics, Chi-square correlation tests such as Pearson, Phi, Cramer\'s V, Kendall\'s tau-b and Spearman, and multiple binary regression analysis were utilized with p-value < 0.05 considered statistically significant. In the models, a regression was performed on the different independent variables, chosen based on the statistical significance of the means between the groups. The goodness-of-fit test was considered significant based on the Omnibus model and the Hosmer and Lemeshow coefficient tests.
Ethical aspects
A study protocol was drawn taking into account the principles of the Declaration of Helsinki in conducting human studies. The project was reviewed and approved by the Research Committee of the Department of General Medicine of the Faculty of Medical Sciences “Salvador Allende”. Prior to enrollment, verbal and documented consent was obtained from the OA during a clinic or home visit, while maintaining confidentiality of personal health information. Although it was not necessary, there was opportunity for a legally authorized caregiver – such as a spouse or child, verified using the Cuban Identity Card and the HSF – to give consent on behalf of eligible OA who were unable to do so.
RESULTS
Table 1 presents characteristics of the study population. The mean age 73.22 years was (S.D.=9.765). The majority of participants were women (64.1%), OA aged 60–69 years (40.6%), white skin color (84.4%), attained university education (31.3%) and retirees (48.4%). Almost all the elderly had a good economic situation (99.2%).
Regarding the health status group, group III predominated, representing 77.3% of participants, followed by group IV comprising 12.5%. Regarding associated pathologies, as shown in Figure 1, there was a predominance of hypertension (71%), followed by ischemic heart disease (24%) and diabetes mellitus (23%). Past medical conditions included dyslipidemia, asthma, cancer, COPD, and kidney failure.
The correlation between sex and the other characteristics showed a significant difference between gender and level of education and employment status, but not other parameters such as age, skin color, economic situation and group of dispensing (Table 2).
Sixteen and four tenths (16.4%) of participants lived alone, while the rest did not. Regarding family functioning, functional families stood at 96.1%, followed by moderately functional (2.3%) and severely dysfunctional (1.6%) families. Housing conditions were good among 122 families (98.4%) and average in 6 (1.6%). There was no overcrowding in 97.7% of homes.
Frailty status was identified in 5.1% OA according to the EGEF. Table 3 shows the frailty among OA according to Cuban criteria. The most frequent alterations were in memory and emotional status (each 7.6%), mobility disorders (6.8%) and sleep disorders (5.1%).
Demographic factors associated with frailty among OA included age, skin color, skin, education level, economic situation and health status (Table 4). Using the model, the prediction of non-frailty improved from 94.9% to 97.5%. The Chi-square value for the model was 35.838 (p < 0.01), and the pseudo-R square (Nagelkerke R Square) was 79.1%. The non-frailty model had a specificity of 66.7% and a sensitivity of 99.1%.
DISCUSSION
Cuba is a nation at an advanced population growth with a high prevalence of OA and low birth rate 1. Despite numerous studies on frailty globally, there is a gap in knowledge on frailty within our health area. Our study identified a prevalence of frailty of approximately 5%, much lower than the previously reported rate of 50% (Cuba), 45% (Mexico), 4.5–17.5% (South America, including Brazil) and 8.5– 13% (Spain) 7,9,10,13,15,30. However, it is important to note that our exclusion criteria (terminally ill and institutionalized people) and failure to identify pre-frailty may have resulted in a lower detection rate of frailty compared to previous studies 16.
Furthermore, PHC is a possible solution to combat the challenges of aging and therefore ongoing PAM activities may have reduced the rate of frailty in our territory 1. These activities include promoting a healthy lifestyle, disease control, provision of family and social support, and reduction of modifiable frailty risk factors. In addition, the elderly report receiving optimum medical care in the CMF (including doctor-patient interviews, physical examination, health status assessment and consultation plan) but inconsistent care during home visits and deficient testing for cancer and general screening 31.
Given the considerable economic and health challenges facing the elderly, this responsibility does not fall solely on the Ministry of Public Health (MINSAP), but involves the entire society, including state and non-governmental organizations, the community and the family 17,32. The family forms the most important aspect in elderly care. Therefore, it is important to understand the composition and characteristics of OA’s families. This study analyzed how sociodemographic factors such as education level, marital status, economic status, employment, housing structure, family type and life partners affect frailty among OA. Our study highlighted the presence of functional families in more than 90% of the OA, followed by families moderately functional and severely dysfunctional. Therefore, there was a predominance of functional families, similar to what was observed in other studies 16. Furthermore, there was rarely any overcrowding or poor housing conditions. Compared to previous studies, the high level of education, modest living conditions and presence of functional families could explain the lower frailty prevalence in our health area 2. According to statistics from the polyclinic and CMF No. 17, majority of the population were > 60 years old (30.5%) with a dependency rate of more than half (59%). In most families, we observed a moderate level of economic income as found in other studies 23. This underscores frailty as a social attribute and not just as a biological function.
Depression and dementia are some of the major geriatric syndromes among senior citizens 22. Globally, depression affects less than 10% of the general population, but its prevalence is 2–5 times higher among the elderly 33. In the present study, we found a prevalence of 4% for depression and 5% for dementia. Our study also identified alterations in mobility, dementia and sleep disorders as the most common CITED Cuban frailty criteria. According to the same criterion, the most significant variables in previous Mexican and Cuban studies were: age > 80 years, isolation, social disorders, mobility and balance disorders, polypharmacy, and EFG alterations 6,34.
According to the World Health Organization (WHO), the elderly can be grouped into three categories: young-old (60 to 74 years), middle-old (75 to 90 years) and very old (> 90 years) 35. The low frailty rate observed in our study is associated with the young-old and middle-old, where the prevalence is between 1.7 –11% 1. Regarding the demographic characteristics of the population studied, our study reported only 2% of very old OA, lower than that of previous studies 3,23. The young-old are at risk of polypharmacy based on previous reports 15,16. During the COVID-19 pandemic, 64.8% of the patients were people aged 60– 74 years, 35.2% were > 75 years and 66.9% of severe COVID-19 cases occurred among > 60 years 1. Except for age, we describe similar participant characteristics compared to earlier studies 1,5,6,16,36. Most OA were < 70 years old, female, and retired.
In our study, the factors associated with frailty among the elderly were age, education, medical group, and skin color. Except for skin color, similar results were described in previous studies, including sex, loneliness and smoking as risk factors 1,7,9. The analysis of health status in our area of Antonio Maceo\'s health revealed a predominance of group III (chronic illness) and group IV (disability or handicap), similar to a previous study 37. Likewise, the comorbidities in our study were similar to previous data from Miramar, where there was a high rate of hypertension, ischemic heart disease, diabetes mellitus, COPD, and cancer 1.Comorbidities among OAs are associated with frailty, which could be attributed to arising complications from chronic diseases or related to polypharmacy 18.18 On the other hand, the female gender is associated with frailty, possibly due to hormonal changes with advancing age 18,20. The probability of robust (non-frail) is lower with skin color, group IV health status, with an Odds Ratio <1. The probability of being frail was associated with sex, marital status and the health status group.
The pathophysiology of frailty involves various processes influenced by the presence of atherosclerosis, COPD, anemia, metabolic factors (diabetes mellitus, hyperinsulinemia, insulin resistance, low albumin), increased cytokines (C-reactive protein, fibrinogen, -antitrypsin, tumor necrosis factor), decreased testosterone, decreased vitamin D, coagulation factors, sarcopenia, obesity, physiological anorexia, pain, and balance disorders 22.
Limitations of the present study are related to the use of secondary data instead of primary data for research. COVID-19 pandemic limited the use of face-to-face interviews, as originally designed, limiting the data collection to available patient records. As a result, data on falls, history of fractures, alcohol consumption, smoking, the presence or absence of a caregiver and in some cases, skin color was missing and could not be obtained.
CONCLUSION
Majority of the elderly people who participated in the study were between 60–69 years old, white-skinned, female, and retired. The most common comorbidities were hypertension, ischemic heart disease, and diabetes mellitus, as observed in previous studies. We reported a low frailty prevalence, much lower than that observed in previous studies in our health area. The most common risk factors for frailty in our study were age, skin color, education level, and dispensary group.
FUTURE IMPLICATIONS:
The low frailty status can be considered as an achievement of the Cuban health system, especially through PHC and PAM. In Havana, a possible intervention to prevent and treat frailty is to promote physical exercise among older adults such as Tai chi, yoga and walking in parks. In addition, supporting monthly social gatherings at the seniors\' home can help reduce isolation and depression among OA. Thirdly, implementation of food supplementation and nutrition programs for frail OA can help combat malnutrition.
DISCLOSURES:
Collaborators: Mutonga, DM, Rodríguez, YA and González, BMG designed and conceptualized the protocol. Mutonga, DM collected the data, performed statistical processing, analysis and interpretation. Mutonga, DM and Rodriguez, YA wrote the first draft of the manuscript. Martínez BMG developed the frailty measurement instrument. Lapadula, MC performed a critical review of the document. All authors reviewed and approved the version.
Acknowledgments: I would like to acknowledge Enfra. Alegna Cabrera Reyes for her support during field visits and assistance in data collection. I thank Dr. C. Eduardo Alemañy Pérez and Dra. Georgia Díaz-Perera Fernández for their valuable training on study design, protocol development and review of the study protocol. Lastly, I appreciate Dr. Odell Rodríguez Hernández for his support in revising the final thesis project and as an assessor in my residency training as a 1st degree specialist in General Medicine Comprehensive.
Financing: This research project did not receive any external funding, but the Mutonga, DM was sponsored to study Comprehensive General Medicine in Cuba from 2018 – 2022 by the Ministry of Health, Kenyan government.
Declaration of Conflicts of Interest: The authors declare that they have no conflicts of interest.
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