Social vulnerability index, physical frailty and delirium in hospitalized older adults

Lenardt, Maria Helena; Cechinel, Clovis; Rodrigues, João Alberto Martins; Marques, Daiane Maria da Silva; Guedez, José Baudilio Belzarez; Binotto, Maria Angélica

doi:10.37689/acta-ape/2025AO0001201

Abstract

Objective To analyze the relationship between the social vulnerability index and physical frailty condition and delirium in hospitalized older adults.

Methods Cross-sectional analytical study of older adults developed in a hospital in southern Brazil. The collection instruments used were a sociodemographic questionnaire, the social vulnerability index, physical frailty phenotype markers and the Confusion Assessment Method. Descriptive and inferential statistics were used.

Results Of the 305 older adults evaluated, 59.4% were female, 40.9% were aged over 80 years and 92.6% had morbidities. There was an association between hospitalization and female sex with low and medium vulnerability (64.8%; 95%CI 55.9-72.7 and 63%; 95%CI 53.2-71.8, respectively, with p=0.0262) . Delirium was observed in 29.5% (95%CI 22.3-38.4) of older adults over 60 years of age with low vulnerability, 17% (10.9-25.5) medium, 14.5% ( 8.6-23.9) high, with p=0.0151. There was no association between delirium and the vulnerability index in older adults aged over 80 years, with p=0.235. Delirium affected 44.3% (32.5-56.7) of older adults with low vulnerability, 35% (22.1-50.5) with medium and 25% (12-44.9) high. There was no association between frailty and social vulnerability, with p=0.927. Among older adults aged 80 years or over, frail people prevailed in the three vulnerability strata (low 59.7%; medium 57.5% and high 56%), p=0.788.

Conclusion Hospitalization and delirium were associated with younger, pre-frail women from low and medium social vulnerability. The condition of frailty did not correlate with social vulnerability. The need to better understand the biopsychosocial factors that can increase delirium in hospitalized older adults with low social vulnerability is highlighted.

Resumo

Objetivo Analisar a relação entre o índice de vulnerabilidade social e condição de fragilidade física e o delirium em idosos hospitalizados.

Métodos Estudo transversal e analítico desenvolvido com idosos em um hospital no Sul do Brasil. Foram empregados os instrumentos de coleta questionário sociodemográfico, índice de vulnerabilidade social, marcadores do fenótipo de fragilidade física e Confusion Assessement Method. Utilizou-se estatística descritiva e inferencial.

Resultados Dos 305 idosos avaliados, 59,4% eram do sexo feminino, 40,9% com idade superior a 80 anos e 92,6% com morbidades. Houve associação entre hospitalização e sexo feminino com baixa e média vulnerabilidade (64,8%; IC95% 55,9-72,7 e 63%; IC95% 53,2-71,8, respectivamente, com p=0,0262). O delirium foi observado em 29,5% (IC95% 22,3-38,4) dos idosos com idade superior a 60 anos com baixa vulnerabilidade, 17% (10,9-25,5) média, 14,5% (8,6-23,9) alta, com p=0,0151. Acima de 80 anos, não se observou associação entre delirium e o índice de vulnerabilidade, com p=0,235. A ocorrência de delirium atingiu 44,3% (32,5-56,7) idosos com baixa vulnerabilidade, 35% (22,1-50,5) média e 25% (12-44,9) alta. Não houve associação entre fragilidade e vulnerabilidade social, com p=0,927. Em idosos com 80 anos ou mais, prevaleceram os frágeis nos três estratos de vulnerabilidade (baixa 59,7%; média 57,5% e alta 56%), p=0,788.

Conclusão A hospitalização e o delirium se associaram a mulheres mais jovens, pré-frágeis e provenientes de baixa e média vulnerabilidade social. A condição de fragilidade não se correlacionou à vulnerabilidade social. Destaca-se a necessidade de melhor compreensão dos fatores biopsicossociais que podem aumentar o delirium em idosos hospitalizados com baixa vulnerabilidade social.

Idoso; Hospitalização; Fragilidade; Delirio; Classe social; Vulnerabilidade social

Resumen

Objetivo Analizar la relación entre el índice de vulnerabilidad social y la condición de debilidad física y el delirium en personas mayores hospitalizadas.

Métodos Estudio transversal y analítico llevado a cabo con personas mayores en un hospital del sur de Brasil. Se emplearon los siguientes instrumentos para la recopilación: cuestionario sociodemográfico, índice de vulnerabilidad social, marcadores del fenotipo de debilidad física y Confusion Assessement Method. Se utilizó la estadística descriptiva e inferencial.

Resultados De las 305 personas mayores evaluadas, el 59,4 % era de sexo femenino, el 40,9 % de más de 80 años y el 92,6 % con morbilidades. Se observó asociación entre hospitalización y sexo femenino con vulnerabilidad baja y mediana (64,8 %; IC95 % 55,9-72,7 y 63 %; IC95 % 53,2-71,8, respectivamente, con p=0,0262). El delirium se observó en el 29,5 % (IC95 % 22,3-38,4) de las personas mayores de más de 60 años con vulnerabilidad baja, el 17 % (10,9-25,5) mediana y el 14,5 % (8,6-23,9) alta, con p=0,0151. No se observó relación entre delirium e índice de vulnerabilidad en personas de más de 80 años, con p=0,235. La incidencia de delirium llegó al 44,3 % (32,5-56,7) de personas mayores con vulnerabilidad baja, 35 % (22,1-50,5) mediana y 25 % (12-44,9) alta. No se observó asociación entre debilidad y vulnerabilidad social, con p=0,927. Entre las personas mayores de 80 años o más, prevalecieron los débiles en las tres categorías de vulnerabilidad (baja 59,7 %; mediana 57,5% y alta 56%), p=0,788.

Conclusión La hospitalización y el delirium se asociaron a mujeres más jóvenes, predébiles y con vulnerabilidad social baja y mediana. La condición de debilidad no se correlacionó con la vulnerabilidad social. Se resalta la necesidad de una mejor comprensión de los factores biopsicosociales que pueden aumentar el delirium en personas mayores hospitalizadas con vulnerabilidad social baja.

Anciano; Hospitalización; Fragilidad; Delirio; Clase social; Vulnerabilidad social

Introduction

Hospitalized older adults often bring with them not only the underlying/chronic disease, but a set of specific characteristics of the context where they reside. The Vulnerability of Coverage Areas of Municipal Health Units Index (Portuguese acronym: IVAB) emerges in this scenario, in which dimensions on the suitability of the home, family profile and composition, access to work, income and educational conditions are considered.(¹)

Social vulnerability in health emerges as a concept used to comprehensively understand the social issues affecting the health of older adults, and the degree to which general social situations make an individual susceptible to poor health outcomes is considered.(²)

Although social vulnerability is important for individuals in any age group, its impact is likely greater in older adults due to the increased incidence of significant social changes.(³) These transitions include retirement, death of a life partner, and dependence on other people for self-care activities, such as shopping or personal hygiene. For some older adults, the accumulation of social changes can result in functional, psychological and physiological decline,(²) often recognized as components of frailty.

Given such relationships, neighborhoods with lower social vulnerability may provide more opportunities to support health and well-being. Neighborhood-based social processes, such as cohesion and social participation protect against frailty through the creation and maintenance of social connections and support networks.(⁴,⁵)

In a scoping review carried out in the United States in 2019, 13 studies involving this topic were analyzed, and an association between frailty and the social and physical characteristics of neighborhood residents was found, including the population’s deprivations, diversity, ethnic heterogeneity, social cohesion and ability to walk. Most studies included in this review assessed frailty using the Cardiovascular Health Study-based phenotype or an index approach. Phenotype measurement assesses the physical components of frailty, while an index approach assesses the physical and psychosocial contributors to the development of frailty.(⁶)

In turn, physical frailty is defined as a clinical state characterized by increased vulnerability in the individual when exposed to internal and external stressors, in addition to being one of the main contributors to functional decline and early mortality in older adults.(⁷)

The condition of frailty was the target of a cross-sectional and analytical study of 1,716 older adults from the community conducted in Curitiba (PR) in which 65.3% pre-frail and 15.8% frail were observed.(⁸) In a systematic review with meta-analysis including 26 studies and the total sample of 13,502 hospitalized older adults, the prevalence of frailty was 34% (95% confidence interval - 95%CI 0.26-0.42, p=0).(⁹)

The aim of a study of 2,413 older adults conducted at the Caboolture Hospital, Australia, was to evaluate frailty and hospital outcomes in an area of socioeconomic disadvantage. The Clinical Frailty Scale (CFS) instrument was associated with the 28-day mortality, and odds of mortality increased 1.5 times per unit increase in CFS (95%CI 1.3-1.7). For the authors, the management of frail older adults must be considered as a priority in interventions and resource allocation in the hospital environment. In that same study, delirium was evidenced in 0.8% of robust older adults and 5% of frail older adults; p<0.001.(¹⁰)

Delirium, which is often identified in older adults in the hospital environment, was associated with employment status and demographic factors, such as age, sex, ethnicity and physical frailty itself.(¹¹) Likewise, in a study conducted in a hospital setting, delirium affected 21% (95%CI 0.17-0.25; p<0.01) of patients. The risk of hospitalized frail older adults developing delirium was 66% (RR 1.66; 95%CI 1.23-2.22; p<0.01).(⁹)

A study of 560 older adults over 70 years of age was conducted in Boston, United States, with the objective to evaluate the association between characteristics of the socioeconomic level of neighborhoods and the incidence and severity of delirium in older adults undergoing major non-cardiac surgery. Social vulnerability was associated with delirium and living in less favored neighborhoods was associated with a higher risk of delirium (46%) compared to more advantaged neighborhoods (23%), p=0.01.(¹²)

Even in developed countries like the United States, it is important to quantify the social determinants of health in their multiple dimensions. It was observed that 9.6% of census sectors presented regions of extreme poverty and, consequently, of greater concern for health professionals and public policy advocates. Although these countries have better Human Development Indexes (HDI), a correlation between social vulnerability and health conditions is observed.(¹³) Such results can be worsened in low-income countries or those with social inequalities.(²,¹²)

To date, no studies investigating the association of social vulnerability with frailty and delirium in hospitalized older adults have been found. Understanding the link between frailty and delirium in hospitalized older adults from a disadvantaged socioeconomic area is relevant, given that socio-environmental vulnerability is considered a contributing factor to readmissions.(¹⁴)

Studies related to the themes of hospitalization, frailty, delirium and social vulnerability can lead to the optimization of resources and the implementation of improvements in the quality and value of healthcare. Furthermore, they emphasize interdisciplinary work in order to achieve comprehensive care within the perspective of the expanded clinic. Interventions targeted at high-risk subpopulations can bring direct benefits and improvements at different levels of healthcare.

In view of the above, the aim of the present study was to analyze the relationship between the social vulnerability index and physical frailty condition and delirium in hospitalized older adults.

Methods

This is a cross-sectional and analytical study of older adults hospitalized in a medium complexity hospital in Curitiba. The sample size calculation was non-probabilistic with a simple random sampling method and outcome in proportions representing the hospitalizations in 2019. The STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) guidance tool translated into Brazilian Portuguese and consisting of a 22-item checklist, was used for the systematic development of the study.(¹⁵)

The study was conducted with secondary data from the database of the project Physical Frailty and Clinical, Functional, Psychosocial, Nutritional and Demand for Care in Hospitalized Older Adults Outcomes, approved by the Research Ethics Committee in Human Beings of the Health Sciences Sector at the Universidade Federal do Paraná (UFPR) under opinion number 4.985.540. The inclusion criteria for participants were: age equal to or over 60 years old; being hospitalized for clinical and/or surgical treatment; presenting the condition of physical frailty stratified by Fried’s phenotype;(¹⁶) having been evaluated with the Confusion Assessment Method (CAM) delirium screening tool.(¹⁷) Residents of cities in the metropolitan region of Curitiba were excluded, as such cities did not have the IVAB measurement available.

Initially, cognitive screening was performed using the Mini Mental State Examination(¹⁸) validated for Brazilian Portuguese,(¹⁹) with the aim of selecting older adults capable of answering the study questionnaires. When the older adult presented cognitive changes and/or communication deficits, the caregiver present at the time of data collection was invited to answer the questions in the presence of the older adult. If the person present at the time of the interview did not feel confident answering the questions, the main caregiver was contacted to obtain reliable information.

The main caregiver is the person responsible for the direct care of the older adult and who has known him/her for at least three months. This main caregiver would have the knowledge to answer the questions related to the physical and mental health of the older adult present in the sociodemographic and clinical questionnaires and the frailty phenotype. This person is usually an informal caregiver, that is, a family member, friend or neighbor who performs such activities without any remuneration.

Data collection consisted of applying a sociodemographic questionnaire with the following variables of interest: age, sex, color, marital status. Frailty was classified using physical frailty phenotype markers, namely: decreased handgrip strength; reduced walking speed; self-report of fatigue/exhaustion; unintentional weight loss and reduction in the level of physical activity.(¹⁶) Delirium was assessed by the CAM,(¹⁷) validated for Brazilian Portuguese.(²⁰) The instrument has four cardinal characteristics that allow distinguishing delirium from other cognitive impairments: acute onset and fluctuating course; attention deficit; disorganized thinking; and change in level of consciousness.

The hospital chosen for data collection is part of the city’s Health Care Network (Portuguese acronym: RAS), and care is 100% linked to the Unified Health System (SUS). The RAS includes Basic Health Units (UBS), which are classified according to the IVAB by the Municipal Health Department. The hospitalized older adults who participated in the study were grouped according to the UBS of origin, identified through consultation of the electronic medical record of the municipality called E-saúde.

The IVAB scores and the categorizations into low, medium and high vulnerability were obtained through the classification of the Health Unit where the older adult came from, in accordance with municipal decree 638, which establishes the IVAB of Municipal Health Units in the Municipal Health Secretariat of Curitiba.(¹)

Four dimensions are taken into consideration in the IVAB: household suitability; family profile and composition; access to work and income; schooling conditions. In the household suitability dimension, type of household, density per bedroom, construction material, presence of running water and sewage network are analyzed. In the family profile and composition, those responsible for the family are assessed, the ratio of children and adolescents to adults, the presence of child labor, the presence of hospitalized children and adolescents, the presence of hospitalized adults, the presence of hospitalized older adults, the presence of people with disabilities, other coresident older adults and illiteracy of the head of the family. Access to work and income takes into account the work of adults and per capita monthly family income. In schooling conditions, the presence of children and adolescents out of school, age and grade gaps, and young people and adults without primary education are analyzed.(¹)

Municipal Health Units located in the first tertile (percentage less than 3.9%) are classified as low vulnerability, in the second tertile as medium vulnerability (percentage greater than or equal to 3.9% and less than 7.8%) and in the third tertile as high vulnerability (percentage greater than or equal to 7.8% up to the upper limit, which can reach 100%).(¹)

Prior to the application of the tests, with the aim of standardizing the execution and minimizing collection biases, theoretical and practical training was given to the examiners, who are members of a research group composed of undergraduate and postgraduate nursing students at an educational institution. A pilot study was conducted with 30 older adults with the objective of assessing the need to adapt the proposed questionnaires and tests. These participants were part of the final sample, as there were no changes to the questionnaires and tests applied. Data were collected from March to July 2022 in the clinical and/or surgical wards of the hospital and the average time to apply the collection instrument was approximately 30 minutes.

Descriptive statistics, mean, standard deviation, median, maximum, minimum were used, with presentation in frequency distribution tables, and the non-parametric chi-square test and the Fisher’s exact test to evaluate the association between the variables of interest in the study. Non-parametric tests were used to compare independent groups given the presence of categorical data. The Fisher’s exact test is an alternative to the chi-square test when the frequency of variables is low, less than five. Statistical analyzes were performed using the R 4.2.1 software, with a confidence level of 95% and a sampling error of 5%.

The study met national ethical standards involving human beings (Certificate of Presentation of Ethical Appreciation: 50459821.0.0000.0102/ Opinion number: 4.985.540).

Results

Of the sample of 305 older adults, there was a predominance of females (59.4%), white (70.6%), married (39.7%) and aged 80 years or over (40.9%). There was an association between the female sex and regions of low (64.8%; 95%CI 55.9-72.7) and medium vulnerability (63.0%; 95%CI 53.2-71.8), with p=0.0262 (Table 1).

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Table 1
Sociodemographic conditions and social vulnerability index

In table 2, a predominance of robust older adults in the low vulnerability condition (14.8%; 95%CI 9.5-22.1) is observed, with a predominance of the pre-frailty condition in the three strata of social vulnerability. Among older adults aged 80 years or over, there was a predominance of frail people in the three vulnerability strata, with no association between frailty and social vulnerability, p=0.788.

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Table 2
Association between physical frailty and social vulnerability index in older adults aged 60 and 80 years and over

In table 3, delirium in older adults aged 60 years or over from low-vulnerability areas was 29.5% (95%CI 22.3-38.4), from medium-vulnerability areas 17% (95%CI 10.9 -25.5) and from high-vulnerability areas 14.5% (95%CI 8.6-23.9), with p=0.0151. In older adults aged 80 years or over, the frequency distribution of delirium in patients from low-vulnerability areas was 44.3% (95%CI 32.5-56.7), from medium-vulnerability areas 35.0% (95%CI 22.1-50.5) and high-vulnerability areas 25.0% (95%CI 12.0-44.9), with p=0.235.

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Table 3
Association between the occurrence of delirium and the social vulnerability index in older adults aged 60 and 80 years and over

Discussion

Women predominate in regions of low and medium vulnerability and men in areas of greater deprivation and/or high vulnerability. A study carried out with data from the Rochester Epidemiology Project (Mayo Clinic) included 197,578 individuals from Minnesota, United States, 49.5% of the sample was aged 50 years or older, and the aim was to determine the association between socioeconomic status, chronic conditions and differences by age, sex, race or ethnicity. The prevalence of chronic conditions and a composite measure of neighborhood socioeconomic disadvantage was estimated, the Area Deprivation Index (ADI). For the cardiometabolic conditions of hyperlipidemia, diabetes mellitus, cardiac arrhythmias and coronary artery disease, the patterns were similar in men and women, but associations were stronger with the increase in the ADI quintile in women, compared to men.(²¹)

Although several studies show that the female aging process involves greater disability, comorbidities and less accumulation of capital (social, financial, health), which makes them more susceptible to the social health gradient,(²,³) this relationship was not observed in hospitalized older adult women. In this study, there was a more significant presence of men among older adults from areas of greater vulnerability. Future research is needed to clarify the developmental factors that lead to these sex differences and identify effective strategies to intervene in the relationship between socioeconomic position and adverse outcomes.

The condition of physical frailty and the differences observed in neighborhoods with socioeconomic and ethnic diversity in San Antonio, Texas, United States, were the subject of a cross-sectional study conducted with 394 older adults aged 65 years or older. The prevalence of frailty was 15.6% in the central neighborhood, 9.4% in the transition neighborhood and 3.5% in the suburbs (p=0.01).(²²) In the present study, there was no evidence of an association between physical frailty and the vulnerability index in hospitalized older adults. There was a predominance of pre-frail older adults in those aged 60 years or over, and frail in those aged 80 years or over. The lack of association between physical frailty and the vulnerability index may be related to the subject selection process and the study design. Since this is a sectional study conducted in a single hospital environment, it presents particularities in the evaluation, such as decompensation of some clinical condition.

A longitudinal study involving the third and fourth stages of the Duke Established Populations for Epidemiologic Studies of the Elderly (EPESE) analyzed 1,740 older adults in an area rich in health services. There was no association between frailty and an unfavorable neighborhood, possibly due to the better health of the sample and easy access to health services.(²³) The literature also points to an association between physical frailty and sociodemographic and clinical factors of older adults, such as low income,(²⁴) age, female sex and low schooling.(⁸)

In a systematic review with meta-analysis conducted in the United Kingdom in 2022, the objective was to evaluate the relationship between social vulnerability, mortality and frailty in older adults. The level of social vulnerability in the meta-analysis measured by the social vulnerability index was 0.3 (95%CI 0.24-0.36). The highest social vulnerability index was observed in Tanzania 0.47 (95%CI 0.44-0.50), while the lowest social vulnerability index was reported in China 0.15 (95%CI 0.15-0.15) . The highest level of the frailty index was 0.32 in Tanzania and Europe, and the lowest frailty reported in a study from the United States was in Hawaii, 0.15. In all studies, social vulnerability was a significant predictor of mortality for both sexes.(²⁵)

In a prospective study conducted in Boston with 560 older adults over 70 years of age, there was an association between social vulnerability and delirium. The objective was to evaluate the association between characteristics of the socioeconomic level of neighborhoods and the incidence and severity of delirium in older adults undergoing major non-cardiac surgery. Living in less favored neighborhoods was associated with a higher risk of delirium (46%), when compared to more advantaged neighborhoods (23%) (risk ratio 2.0; 95%CI 1.3–3.1, with p=0 .01).(¹²) These data differ from those found in the present study; among older adults aged 60 years or over, 29.5% from low-vulnerability regions presented delirium and 14.5% of those from high-vulnerability regions, with p=0.0151. Delirium is known to be underdiagnosed, and its screening depends on the training of health professionals.(²⁶) Regions of low vulnerability may have greater access to professional caregivers, trained in identifying subtle changes in the mental state of older adults, hence there is an earlier referral to the hospital environment. Studies that can elucidate this hypothesis, assessing the type of care, professional or not, in each segment of social vulnerability should be encouraged. Understanding the psychosocial factors that may lead to increased delirium in hospitalized older adults is important for managing this condition.

The frequency distribution of delirium in older adults aged 80 years or over from low-vulnerability areas was 44.3% (95%CI 32.5-56.7), from medium vulnerability 35% (95%CI 22.1 -50.5) and from high vulnerability areas 25% (95%CI 12.0-44.9). Even though the increase in delirium in older adults aged 80 or over is significant, there was no association with social vulnerability.

The use of tools for assessing social vulnerability, such as the IVAB, allows the objective comparison of health units, identifying areas that require a greater contribution of resources from the state, striving for the principle of equity in the SUS. The identification of social vulnerability within the territory from a perspective beyond the identification of poverty (insufficiency of income) and the relationship with hospitalization, physical frailty and delirium, encourages thinking about individualized healthcare and nursing care management plans.

The limitations of the study include the sectional design, which does not allow the establishment of a cause-effect relationship, the presence of different instruments for assessing different strata of social vulnerability and the failure in screening clinical risk factors for the occurrence of delirium.

Conclusion

There was an association between hospitalization and delirium in younger older adult women from regions of low and medium social vulnerability. This association was not observed in older adult women from highly vulnerable regions. Physical frailty evolves with increasing age, since pre-frailty predominates in younger older adults aged 60 years or over, and the frail condition in those over 80 years of age. Physical frailty showed no relationship with the social vulnerability index, while delirium showed a relationship with areas of lower social vulnerability index in younger older adults aged between 60 and 80 years. Individual factors must be interpreted within the broader context of indicators of social disadvantage, highlighting the need for a complex and multifactorial approach to planning care for hospitalized older adults. The psychosocial factors that can lead to an increase in delirium in hospitalized older adults from areas of low social vulnerability need to be better understood.

References

¹ Diário Oficial Eletrônico. Atos do Município de Curitiba. Decreto No 638 de 21 de junho de 2018. Institui o Índice de Vulnerabilidade das Áreas de Abrangência das Unidades Municipais de Saúde - IVAB. Curitiba (PR): Diário Oficial do Município; 2018 [citado 2023 Dez 15]. Disponível em: https://legisladocexterno.curitiba.pr.gov.br/DiarioConsultaExterna_Pesquisa.aspx
» https://legisladocexterno.curitiba.pr.gov.br/DiarioConsultaExterna_Pesquisa.aspx
² Nguyen TN, Ngangue P, Bouhali T, Ryan BL, Stewart M, Fortin M. Social vulnerability in patients with multimorbidity: a cross-sectional analysis. Int J Environ Res Public Health. 2019;16(7):1244.
³ Cappelli M, Bordonali A, Giannotti C, Montecucco F, Nencioni A, Odetti P, et al. Social vulnerability underlying disability amongst older adults: A systematic review. Eur J Clin Invest. 2020;50(6):e13239.
⁴ Caldwell JT, Lee H, Cagney KA. Disablement in Context: Neighborhood Characteristics and Their Association With Frailty Onset Among Older Adults. J Gerontol B Psychol Sci Soc Sci. 2019;74(7):e40-9.
⁵ Prior L. Allostatic load and exposure histories of disadvantage. Int J Environ Res Public Health. 2021;18(14):7222.
⁶ Fritz H, Cutchin MP, Gharib J, Haryadi N, Patel M, Patel N. Neighborhood characteristics and frailty: a scoping review. Gerontologist. 2020;60(4):e270-85.
⁷ Dent E, Morley JE, Cruz-Jentoft AJ, Woodhouse L, Rodríguez-Mañas L, Fried LP, et al. Physical Frailty: ICFSR International Clinical Practice Guidelines for Identification and Management. J Nutr Health Aging. 2019;23(9):771-87.
⁸ Melo Filho J, Moreira NB, Vojciechowski AS, Biesek S, Bento PC, Gomes AR. Frailty prevalence and related factors in older adults from southern Brazil: A cross-sectional observational study. Clinics (São Paulo). 2020;75:e1694.
⁹ Cechinel C, Lenardt MH, Rodrigues JA, Binotto MA, Aristides MM, Kraus R. Frailty and delirium in hospitalized older adults: A systematic review with meta-analysis. Rev Lat Am Enfermagem. 2022;30:e3687.
¹⁰ Clark S, Shaw C, Padayachee A, Howard S, Hay K, Frakking TT. Frailty and hospital outcomes within a low socioeconomic population. QJM. 2019;112(12):907-13.
¹¹ Cohen S, Doyle WJ, Baum A. Socioeconomic status is associated with stress hormones. Psychosom Med. 2006;68(3):414-20.
¹² Arias F, Chen F, Fong TG, Shiff H, Alegria M, Marcantonio ER, et al. Neighborhood-level social disadvantage and risk of delirium following major surgery. J Am Geriatr Soc. 2020;68(12):2863-71.
¹³ Kolak M, Bhatt J, Park YH, Padrón NA, Molefe A. Quantification of neighborhood-level social determinants of health in the continental United States. JAMA Netw Open. 2020;3(1):e1919928.
¹⁴ Cooksley T, Nanayakkara PW, Nickel CH, Subbe CP, Kellett J, Kidney R, et al.; safer@home consortium. Readmissions of medical patients: an external validation of two existing prediction scores. QJM. 2016;109(4):245-8.
¹⁵ Malta M, Cardoso LO, Bastos FI, Magnanini MM, Silva CM. STROBE initiative: guidelines on reporting observational studies. Rev Saude Publica. 2010;44(3):559-65.
¹⁶ Fried LP, Tangen CM, Walston J, Newman AB, Hirsch C, Gottdiener J, et al.; Cardiovascular Health Study Collaborative Research Group. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001;56(3):M146-56.
¹⁷ Inouye SK, van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Ann Intern Med. 1990;113(12):941-8.
¹⁸ Folstein MF, Folstein SE, McHugh PR. "Mini-mental state". A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975;12(3):189-98.
¹⁹ Bertolucci PH, Brucki SM, Campacci SR, Juliano Y. O Mini-Exame do Estado Mental em uma população geral. Impacto da escolaridade. Arq Neuropsiquiatr. 1994;52(1):1-7.
²⁰ Fabbri RM, Moreira MA, Garrido R, Almeida OP. Validity and reliability of the Portuguese version of the Confusion Assessment Method (CAM) for the detection of delirium in the elderly. Arq Neuropsiquiatr. 2001;59 2-A:175-9.
²¹ Chamberlain AM, St Sauver JL, Finney Rutten LJ, Fan C, Jacobson DJ, Wilson PM, et al. Associations of Neighborhood Socioeconomic Disadvantage With Chronic Conditions by Age, Sex, Race, and Ethnicity in a Population-Based Cohort. Mayo Clin Proc. 2022;97(1):57-67.
²² Espinoza SE, Hazuda HP. Frailty prevalence and neighborhood residence in older Mexican Americans: the San Antonio longitudinal study of aging. J Am Geriatr Soc. 2015;63(1):106-11.
²³ King KE, Fillenbaum GG, Cohen HJ. A cumulative deficit laboratory test-based frailty index: personal and neighborhood associations. J Am Geriatr Soc. 2017;65(9):1981-7.
²⁴ Jürschik Giménez P, Escobar Bravo MÁ, Nuin Orrio C, Botigué Satorra T. Criterios de fragilidad del adulto mayor. Estudio piloto. Aten Primaria. 2011;43(4):190-6.
²⁵ Ayeni A, Sharples A, Hewson D. The Association between social vulnerability and frailty in community dwelling older people: a systematic review. Geriatrics (Basel). 2022;7(5):104.
²⁶ Ritter SR, Cardoso AF, Lins MM, Zoccoli TL, Freitas MP, Camargos EF. Underdiagnosis of delirium in the elderly in acute care hospital settings: lessons not learned. Psychogeriatrics. 2018;18(4):268-75.

Edited by

Associate Editor:
Meiry Fernanda Pinto Okuno (https://orcid.org/0000-0003-4200-1186) Escola Paulista de Enfermagem, Universidade Federal de São Paulo, São Paulo, SP, Brazil

Publication Dates

Publication in this collection
02 Dec 2024
Date of issue
2025

History

Received
11 May 2023
Accepted
17 June 2024

This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

[1] ¹ Diário Oficial Eletrônico. Atos do Município de Curitiba. Decreto No 638 de 21 de junho de 2018. Institui o Índice de Vulnerabilidade das Áreas de Abrangência das Unidades Municipais de Saúde - IVAB. Curitiba (PR): Diário Oficial do Município; 2018 [citado 2023 Dez 15]. Disponível em: https://legisladocexterno.curitiba.pr.gov.br/DiarioConsultaExterna_Pesquisa.aspx
» https://legisladocexterno.curitiba.pr.gov.br/DiarioConsultaExterna_Pesquisa.aspx

[2] ² Nguyen TN, Ngangue P, Bouhali T, Ryan BL, Stewart M, Fortin M. Social vulnerability in patients with multimorbidity: a cross-sectional analysis. Int J Environ Res Public Health. 2019;16(7):1244.

[3] ³ Cappelli M, Bordonali A, Giannotti C, Montecucco F, Nencioni A, Odetti P, et al. Social vulnerability underlying disability amongst older adults: A systematic review. Eur J Clin Invest. 2020;50(6):e13239.

[4] ⁴ Caldwell JT, Lee H, Cagney KA. Disablement in Context: Neighborhood Characteristics and Their Association With Frailty Onset Among Older Adults. J Gerontol B Psychol Sci Soc Sci. 2019;74(7):e40-9.

[5] ⁵ Prior L. Allostatic load and exposure histories of disadvantage. Int J Environ Res Public Health. 2021;18(14):7222.

[6] ⁶ Fritz H, Cutchin MP, Gharib J, Haryadi N, Patel M, Patel N. Neighborhood characteristics and frailty: a scoping review. Gerontologist. 2020;60(4):e270-85.

[7] ⁷ Dent E, Morley JE, Cruz-Jentoft AJ, Woodhouse L, Rodríguez-Mañas L, Fried LP, et al. Physical Frailty: ICFSR International Clinical Practice Guidelines for Identification and Management. J Nutr Health Aging. 2019;23(9):771-87.

[8] ⁸ Melo Filho J, Moreira NB, Vojciechowski AS, Biesek S, Bento PC, Gomes AR. Frailty prevalence and related factors in older adults from southern Brazil: A cross-sectional observational study. Clinics (São Paulo). 2020;75:e1694.

[9] ⁹ Cechinel C, Lenardt MH, Rodrigues JA, Binotto MA, Aristides MM, Kraus R. Frailty and delirium in hospitalized older adults: A systematic review with meta-analysis. Rev Lat Am Enfermagem. 2022;30:e3687.

[10] ¹⁰ Clark S, Shaw C, Padayachee A, Howard S, Hay K, Frakking TT. Frailty and hospital outcomes within a low socioeconomic population. QJM. 2019;112(12):907-13.

[11] ¹¹ Cohen S, Doyle WJ, Baum A. Socioeconomic status is associated with stress hormones. Psychosom Med. 2006;68(3):414-20.

[12] ¹² Arias F, Chen F, Fong TG, Shiff H, Alegria M, Marcantonio ER, et al. Neighborhood-level social disadvantage and risk of delirium following major surgery. J Am Geriatr Soc. 2020;68(12):2863-71.

[13] ¹³ Kolak M, Bhatt J, Park YH, Padrón NA, Molefe A. Quantification of neighborhood-level social determinants of health in the continental United States. JAMA Netw Open. 2020;3(1):e1919928.

[14] ¹⁴ Cooksley T, Nanayakkara PW, Nickel CH, Subbe CP, Kellett J, Kidney R, et al.; safer@home consortium. Readmissions of medical patients: an external validation of two existing prediction scores. QJM. 2016;109(4):245-8.

[15] ¹⁵ Malta M, Cardoso LO, Bastos FI, Magnanini MM, Silva CM. STROBE initiative: guidelines on reporting observational studies. Rev Saude Publica. 2010;44(3):559-65.

[16] ¹⁶ Fried LP, Tangen CM, Walston J, Newman AB, Hirsch C, Gottdiener J, et al.; Cardiovascular Health Study Collaborative Research Group. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001;56(3):M146-56.

[17] ¹⁷ Inouye SK, van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Ann Intern Med. 1990;113(12):941-8.

[18] ¹⁸ Folstein MF, Folstein SE, McHugh PR. "Mini-mental state". A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975;12(3):189-98.

[19] ¹⁹ Bertolucci PH, Brucki SM, Campacci SR, Juliano Y. O Mini-Exame do Estado Mental em uma população geral. Impacto da escolaridade. Arq Neuropsiquiatr. 1994;52(1):1-7.

[20] ²⁰ Fabbri RM, Moreira MA, Garrido R, Almeida OP. Validity and reliability of the Portuguese version of the Confusion Assessment Method (CAM) for the detection of delirium in the elderly. Arq Neuropsiquiatr. 2001;59 2-A:175-9.

[21] ²¹ Chamberlain AM, St Sauver JL, Finney Rutten LJ, Fan C, Jacobson DJ, Wilson PM, et al. Associations of Neighborhood Socioeconomic Disadvantage With Chronic Conditions by Age, Sex, Race, and Ethnicity in a Population-Based Cohort. Mayo Clin Proc. 2022;97(1):57-67.

[22] ²² Espinoza SE, Hazuda HP. Frailty prevalence and neighborhood residence in older Mexican Americans: the San Antonio longitudinal study of aging. J Am Geriatr Soc. 2015;63(1):106-11.

[23] ²³ King KE, Fillenbaum GG, Cohen HJ. A cumulative deficit laboratory test-based frailty index: personal and neighborhood associations. J Am Geriatr Soc. 2017;65(9):1981-7.

[24] ²⁴ Jürschik Giménez P, Escobar Bravo MÁ, Nuin Orrio C, Botigué Satorra T. Criterios de fragilidad del adulto mayor. Estudio piloto. Aten Primaria. 2011;43(4):190-6.

[25] ²⁵ Ayeni A, Sharples A, Hewson D. The Association between social vulnerability and frailty in community dwelling older people: a systematic review. Geriatrics (Basel). 2022;7(5):104.

[26] ²⁶ Ritter SR, Cardoso AF, Lins MM, Zoccoli TL, Freitas MP, Camargos EF. Underdiagnosis of delirium in the elderly in acute care hospital settings: lessons not learned. Psychogeriatrics. 2018;18(4):268-75.

Variables	Low vulnerability		Medium vulnerability		High vulnerability		p-value
Variables	(n=122)	95%CI	(n=100)	95%CI	(n=83)	95%CI	p-value
Sex
Female	79	64.8% (55.9-72.7)	63	63.0% (53.2-71.8)	39	47.0% (36.6-57.6)	0.0262*
Male	43	35.2% (27.3-44.1)	37	37.0% (28.2-46.8)	44	53.0% (42.4-63.4)
Age
60-70	28	23.0% (16.4-31.2)	27	27.0% (19.3-36.4)	27	32.5% (23.4-43.2)	0.0632*
70-80	32	26.2% (19.2-34.7)	33	33.0% (24.6-42.7)	31	37.3% (27.7-48.1)
80 or older	62	50.8% (42.1-59.5)	40	40.0% (30.9-49.8)	25	30.1% (21.3-40.7)
Color
White	88	72.1% (63.6-79.3)	74	74.0% (64.6-81.6)	54	65.1% (54.3-74.4)	0.731^†
Brown/mixed race	26	21.3% (15.0-29.4)	20	20.0% (13.3-28.9)	19	22.9% (15.2-33.0)
Black	7	5.7% (2.8-11.4)	5	5.0% (2.2-11.2)	9	10.8% (5.8-19.3)
Yellow	1	0.8% (0.1-4.5)	1	1.0% (0.2-5.4)	1	1.2% (0.2-6.5)
Marital status
Single	10	8.2% (4.5-14.4)	3	3.0% (1.0-8.5)	4	4.8% (1.9-11.7)	0.285^†
Married	44	36.1% (28.1-44.9)	37	37.0% (28.2-46.8)	40	48.2% (37.8-58.8)
Separated	13	10.7% (6.3-17.4)	12	12.0% (7.0-19.8)	11	13.3% (7.6-22.2)
Widowed	55	45.1% (36.5-53.9)	48	48.0% (38.5-57.7)	28	33.7% (24.5-44.4)

Age ≥ 60 years	Low vulnerability		Medium vulnerability		High vulnerability		p-value
Age ≥ 60 years	(n=122)	95%CI	(n=100)	95%CI	(n=83)	95%CI	p-value
Frailty
Non frail	18	14.8% (9.5-22.1)	13	13.0% (7.8-21.0)	12	14.5% (8.5-23.6)	0.927^*
Pre-frail	56	45.9% (37.3-54.7)	52	52.0% (42.3-61.5)	39	47.0% (36.6-57.6)
Frail	48	39.3% (31.1-48.2)	35	35.0% (26.4-44.7)	32	38.6%(28.8-49.3)
Age ≥ 80 years	Low vulnerability		Medium vulnerability		High vulnerability		p-value
Age ≥ 80 years	(n=62)	95%CI	(n=40)	95%CI	(n=25)	95%CI	p-value
Frailty
Non frail	7	11.3% (5.6-21.5)	3	7.5% (2.6-19.9)	1	4.0% (0.7-19.5)	0.788^†
Pre-frail	18	29% (19.2-41.3)	14	35.0% (22.1-50.5)	10	40.0% (23.4-59.3)
Frail	37	59.7% (47.3-71.0)	23	57.5% (42.2-71.5)	14	56.0% (37.1-73.3)

Age ≥ 60 years	Low vulnerability		Medium vulnerability		High vulnerability		p-value
Age ≥ 60 years	(n=122)	IC95%	(n=100)	IC95%	(n=83)	IC95%	p-value
Delirium
No	85	69.7% (61.6-77.7)	83	83.0% (74.5-89.1)	70	84.3% (76.1-91.4)	0.0151^*
Yes	36	29.5% (22.3-38.4)	17	17.0% (10.9-25.5)	12	14.5% (8.6-23.9)
Missing	1	(0.8%)	0	(0%)	1	(1.2%)
Age ≥ 80 years	Low vulnerability		Medium vulnerability		High vulnerability		p-value
Age ≥ 80 years	(n=61)	95%CI	(n=40)	95%CI	(n=24)	95%CI	p-value
Delirium
No	34	55.7% (43.3-67.5)	26	65.0% (49.5-77.9)	18	75.0% (55.1-88.0)	0.235^†
Yes	27	44.3% (32.5-56.7)	14	35.0% (22.1-50.5)	6	25.0% (12.0-44.9)