Disponibilidade de cuidado em pessoas idosas frágeis: impactos na gestão do cuidado em um contexto de crise — Estudo Fibra

Cad Saúde Colet cadsc Cadernos Saúde Coletiva Cad. Saúde. Colet. 2358-291X 1414-462X Instituto de Estudos em Saúde Coletiva da Universidade Federal do Rio de Janeiro Resumo Introdução: No Brasil, a maioria do cuidado prestado é informal, mas a sua disponibilidade permanece pouco explorada no contexto da fragilidade. Objetivo: Descrever a disponibilidade de cuidado em idosos frágeis de Belo Horizonte (Minas Gerais) e verificar se isso é associado à fragilidade. Método: Trata-se de um estudo transversal, baseado em 598 idosos participantes do estudo Fibra – Belo Horizonte (2008/2009). A fragilidade foi definida por meio de cinco itens do fenótipo da fragilidade física. A disponibilidade de cuidado incluiu medidas objetivas e subjetivas. As variáveis de ajuste foram idade, sexo, escolaridade e autoavaliação da saúde. A análise estatística foi baseada no modelo de regressão de Poisson com variância robusta. Resultados: A prevalência de fragilidade foi de 11,4% e da pré-fragilidade foi de 56,4%. A disponibilidade de cuidado foi um pouco menor entre os frágeis do que em relação aos pré-frágeis e não frágeis, dos quais 17% moravam sozinhos, 14% não tinham ninguém para cuidar e 13% não tinham filhos. Foi observada uma associação entre a falta de disponibilidade de cuidado e a fragilidade, apenas entre os homens, em relação a morar sozinho e a não ter ninguém com quem contar. Conclusão: Somente uma pequena parte dos idosos apresentam falta de disponibilidade de cuidado, que é um pouco maior entre os frágeis. Faz-se necessário um foco nos homens com ausência de disponibilidade de cuidado devido à maior probabilidade de apresentar fragilidade ou pré-fragilidade. INTRODUCTION Considering the population aging, the burden of frailty has become a challenge for both public health systems and family care since it is one of the major conditions associated with aging1. In case of middle-income countries, such as Brazil, this phenomenon demands even more attention because of the steep growth of older adults in the last and further decades2. Frailty is a multidimensional syndrome that involves the interaction of biological, psychological, and social factors3. There is a lack of consensus in the literature regarding the practical measure of frailty in clinical settings, showing numerous scales based on different conceptual definitions4. However, there is a widespread performance-based phenotype3 that may be useful in clinical settings5. It comprises five positive phenotypic criteria: unintentional weight loss, measured by self-report of losing more than 10 pounds in the last year; self-reported exhaustion, answering moderate or most of the time for the following two items of the CES-D Depression Scale: the feeling that everything they did was an effort, and that they could not get going; weakness, measured by grip strength using cutoffs according to sex and body mass index; slowness, measured by walking speed using cutoffs according to sex and height; low physical activity, originally measured using the short version of the Minnesota Leisure Time Activity questionnaire3. The prevalence and incidence of frailty and pre-frailty vary across countries’ incomes (higher in middle-income countries) and types of frailty definitions6. The literature reports that the prevalence of frailty ranges from 3.9% in China to 51.4% in Cuba4. In Brazil, according to a recently published meta-analyses, it varies from 8 to 47%7. Additionally, a representative population-based study of older Brazilian adults found a prevalence of 13.5% (95% confidence interval [CI] 11.9–15.3) among older adults aged 60 years and over, and 16.2% (95%CI 14.3–18.3) among those aged 65 years and over8. Regardless of its operational definition, it is well known that frailty is associated with a higher risk of adverse outcomes such as physical disability and long-term care9. Both frailty and pre-frailty were statistically at higher risk of needing long-term care10. This increased demand will have multiple implications for individuals, families, health systems, and the larger society. One of the main implications is the higher healthcare costs (increasing by nearly 54%) particularly observed in the inpatient sector and informal nursing care11. Recently, this scenario has become even worse considering the current Brazilian economic crisis where the Gross Domestic Product (GDP) has been decreasing since 201112, and the lack of priority given to the Unified Health System (in Portuguese Sistema Único de Saúde), reinforced by Constitutional Amendment No. 95 (EC-95/2016), which freezes the public budget for 20 years13. In Brazil, patients often remain with their family, with some source of support from civil and/or religious communities rather than going to long-stay institutions (nursing homes)14. Most of the care (68.5%15) is provided by the nuclear family, which is considered an important and cheapest (i.e., normally unpaid) source of informal care. However, considering that nowadays older adults are significantly less likely to have a spouse or a grown child living nearby (smaller nuclear family network)16, the availability of informal care remains relatively little explored in the context of frailty. For example, in the United States, unmarried frail older adults without children are about 31% less likely to receive unpaid help from family and friends than those with two or more adult children17. In China, childless individuals whose children have all died exhibit worse self-rated health than individuals with children18. However, another study in Belgium showed that only 15.8% of high frail older adults in need of assistance do not receive help15. Qualitatively, the geographical accessibility, the lack of having someone around, and the absence of trust in care providers have been reported as barriers to care access19. There are two types of measuring the availability of informal care: objective, considering the number of people available for taking care in case of need (number of children, number of people living with), and subjective, including the expectation of support for care, related to the belief that close individuals will provide the necessary support in case of need20. A Brazilian study has demonstrated that subjective measures of support, as well as objective measures, are sensitive predictors of functioning21. Therefore, this study aimed to describe the availability of care among older adults and its association with frailty. We believe that older adults with a smaller nuclear family network are more likely to have worse health indicators regarding frailty. METHODS Data source and sampling This is a descriptive cross-sectional analysis based on the Frailty in Brazilian Older People (in Portuguese, Fraigilidade emidosos brasileiros [Fibra]) Study’s participants living in Belo Horizonte, from Universidade Federal de Minas Gerais pole. The Fibra Study is a multicenter network conducted in several Brazilian municipalities, including Belo Horizonte-MG (Fibra-BH). The Fibra-BH sample size was calculated to reach 50% of determined characteristics, according to the population total number of the municipality (i.e., higher than 1 million). It was a two-stage cluster sample design where the census enumeration areas of the Brazilian Institute of Geography and Statistics were randomly selected and regarding the older adult population size in the selected census enumeration areas, we set the minimum interviews in both census enumeration areas and localities. Details of sampling design are available elsewhere22. The inclusion criteria of the Fibra-BH study included being 65 years old and over, being community-dwelling, and having Mini-Mental State Examination23 score higher than 17 (i.e., without cognitive impairment). Participants were excluded if they had any stroke, had Parkinson’s disease, were using a wheelchair, and were bedridden24. Data were collected in 2008/2009 by interviewers trained previously. For the current analyses, we included only older adults with complete information on the studying variables. All participants signed informed consent. The Fibra-BH was approved by the Federal University Ethics Committee (ethic no. 187/07). Measures The dependent variable was frailty. The definition of frailty was made using the frailty phenotype proposed by Fried et al.3, comprising five positive phenotypic criteria (unintentional weight loss, self-reported exhaustion, weakness, slowness, and low physical activity). Accordingly, community-dwelling older adults were classified as frail (three or more criteria), pre-frail (one or two criteria), and non-frail (no criterion). For statistical purposes, taking into account that both frailty and pre-frailty were statistically at higher risk of needing long-term care10, we combined the frail and pre-frail groups and compared with the non-frail group. The target determinants of frailty were the availability of care. We used three measures to assess the availability of care: living arrangement (living alone, living with a partner or children, and other arrangements, including living with a caregiver or friends or other family members); expectation for care, accessed by having nobody to rely on when in need (yes/no); number of children alive, including those living outside the household (continuous). We used sociodemographic and health characteristics as adjusting variables. Sociodemographic characteristics included age, sex, and complete years of education. Health characteristics included self-rated health, a simple measure that predicts mortality similar to objective measures25, dichotomized into very good/good and fair/bad/very bad. We categorized years of education into three categories: <4 years, 4–8 years, and ≥9 years. Statistical methods These descriptive analyses were based on different statistical methods: first, we used Pearson’s χ2 test with Rao-Scott correction and t-test, according to the sort of variable (categorical or continuous, respectively), to set a crude descriptive analysis, and second, we implemented the Poisson regression model with a robust error variance to estimate prevalence ratios (PR) and their 95%CIs, adjusted by sociodemographic characteristics and self-rated health. Adjusted models were performed separately for every variable of the availability of care and stratified by sex. All analyses were performed using STATA 13.0 (Stata Corp LLP, College Station, TX), considering the sampling parameters (individual weight and household clustering of individuals). RESULTS Of the 606 Fibra-BH study participants living in Belo Horizonte, 598 (98.7%) had complete information about the studying variables and were included in the current analysis. The characteristics of the study population by frailty/pre-frailty classification are shown in Table 1. The mean age of the participants was 74.3 years (SD=6.4), with females being the majority (66.5%). The prevalence of frailty was 11.4% and pre-frailty was 56.4%, with a total prevalence of 67.8%. The availability of care was statistically similar among frail/pre-frail and non-frail older adults, but slightly lower among frail/pre-frail: 16.1% of frail/pre-frail older adults have been living alone, and 9% have nobody to rely on and presented a mean number of children of 4 (SD=2.8). Table 1 Descriptive analysis of the participants according to frailty/pre-frailty status – Frailty in Brazilian Older People (Fibra) Study, Belo Horizonte-MG (2008–2009). Variables Total Frailty/pre-frailty p-value No Yes Female sex, (%) 66.5 20.4 46.0 0.397a Age, mean (SD) 74.3 (6.4) 72.2 (5.5) 75.3 (6.6) <0.001b Years of education, (%) 0.012a  <4 27.8 6.7 21.1  4–8 46.8 14.6 32.2  9+ 25.4 10.9 14.5 Self-rated health, (%) <0.001a  Very good/good 61.3 78.5 53.1  Fair/bad/very bad 38.7 21.5 46.9 Number of children, mean (SD) 3.9 (2.7) 3.9 (2.6) 4.0 (2.8) 0.723b Living arrangement, (%) 0.539a  Living alone 14.7 11.9 16.1  Living with a partner or children 40.7 42.0 40.2 Other arrangements 44.6 46.2 43.8 Expectation for care, (%) 0.059a  Somebody to rely on 88.7 97,6 91.0  Nobody to rely on 11.3 2.4 9.0 Total (N)value# 598 182 416 a Based on Pearson’s χ2 test with Rao-Scott correction; b Based on the t-test; Note: estimated percentages, considering the sampling parameters; # Total sample without sampling parameters. Figure 1 shows the lack of availability of care according to the frailty status. Only a small percentage of older adults (nearly 12%) showed a lack of availability of care. However, frail and pre-frail older adults showed a slightly higher lack of availability of care compared to non-frail, regarding nobody to rely on (around 14% vs. 9%), living alone (14 and 17% vs. 10%, respectively), and childless (around 13% vs. 9%). Among frail individuals, the lack of availability of care is higher regarding living alone, where 17% have been living alone. However, none of these differences were statistically significant. Figure 1 Percentage of older adults with a lack of availability of care according to the frailty status — Frailty in Brazilian Older People (Fibra) Study, Belo Horizonte-MG, n=598 (2008–2009). Table 2 shows the adjusted prevalence and PR of the multivariate association between frailty/pre-frailty and the availability of care overall and for men and women separately. Taking all these into consideration, we did not observe any association between frailty/pre-frailty and the availability of care. However, even after adjustments, the expected probability of frailty/pre-frailty was slightly higher among those living alone (72%) and those with nobody to rely on (74.3%). After the stratification by sex, the results showed an association only among men. The predicted probability of frailty/pre-frailty was statistically higher among men living alone (89.5%) and those having nobody to rely on (78.2%). Additionally, a lower prevalence of frailty/pre-frailty for those living with a partner or children (PR=0.65; 95%CI 0.49–0.86) and for other living arrangements (PR=0.72; 95%CI 0.55–0.96) compared to those living alone, and a positive association between nobody to rely on and frailty/pre-frailty were found (PR=1.24; 95%CI 1.01–1.52). No association was found among women. However, the predicted probability of frailty/pre-frailty was slightly higher among women with nobody to rely on (73.2%) compared to those with somebody to rely on (68.4%). Table 2 Expected probability of frailty/pre-frailty and prevalence ratios of the multivariate association between frailty/pre-frailty and the availability of care in 598 older adults – Frailty in Brazilian Older People (Fibra) Study, Belo Horizonte-MG (2008–2009). Variables Overall (men and women) Men Women Expected probability of frailty/pre-frailty1 (%) Frailty/pre-frailty Expected probability of frailty/pre-frailty2 (%) Frailty/pre-frailty Expected probability of frailty/pre-frailty2 (%) Frailty/pre-frailty Overall PR 95%CI PR 95%CI PR 95%CI Number of children 71.2 (childless) 0.99 0.97–1.01 68.4 (childless) 0.99 0.94–1.04 72.2 (childless) 0.99 0.96–1.01 Living arrangement  Living alone 72.0 1.00 89.5 1.00 69.9 1.00  Living with a partner or children 67.8 0.93 0.77– 1.20 58.3 0.65 0.49–0.86* 72.6 1.04 0.83–1.31  Other arrangements 67.1 0.93 0.77–1.13 64.9 0.72 0.55–0.96* 65.9 0.94 0.74–1.19 Expectation for care  Somebody to rely on 66.8 1.00 63.3 1.00 68.4 1.00  Nobody to rely on 74.3 1.11 0.98–1.29 78.2 1.24 1.01–1.52* 73.2 1.07 0.88–1.30 95%CI: 95% confidence intervals; PR: prevalence ratio; 1 Adjusting for age, sex, years of education, and self-rated health; 2 Adjusting for age, years of education, and self-rated health, stratifying by sex for men and women; * p<0.05. DISCUSSION According to the current study, only a small percentage of older adults showed a lack of availability of care. However, the pre-frail and frail older adults showed a slightly higher lack of availability of care compared to non-frail. Considering frail older adults, the higher percentage of lack of availability of care is the older adults living alone. Our multivariate model showed that having nobody to rely on when they are in need and the living arrangement were associated with frailty/pre-frailty only among men. Those living with a partner or children and other living arrangements rather than living alone showed a lower prevalence of frailty/pre-frailty. Moreover, we found a prevalence of frailty of 11.4%, similar to other studies conducted in Brazil4,7,8,22. Frailty and pre-frailty are conditions that demand long-term care10, and our results show that these categories have a higher lack of availability of care. In the current analyses, we considered the availability of care instead of the care effectively provided. In a convenience sample of older adults in Montes Claros, Minas Gerais, the authors found that most of the frailty older adults (70.7%) had a caregiver. Indeed, the definition of frailty was made differently based on the nine domains of the Edmonton Frail Scale26. However, our groups fit older adults at risk of having a limited source of care and need special attention from health professionals. When we stratified by sex, we found a slightly higher but not significant probability of having frailty/pre-frailty among men having nobody to rely on compared to women (78.2 and 73.2%, respectively), showing an association with frailty/pre-frailty only among men (PR=1.24; 95%CI 1.01–1.52). Indeed, it has been noted that people in need of support or care, such as frail individuals, are often those least likely to receive support27 and medical care as they thought they needed28. Moreover, literature shows that men report lower levels of social support compared to women29, probably because men’s social support is heavily focused on their spouses, whereas women are much more likely to rely on a child, close relative, or a friend27–29. Regardless of the reason to perceive having nobody to rely on, we also found a slightly higher probability of having frailty/pre-frailty among men living alone than women living alone (89.5 and 69.9%, respectively). Regardless of women showing a statistically nonsignificant high prevalence of frailty compared to men (46 and 21.9%, respectively), men with a lack of informal care availability are more likely to have frailty and demand special attention from the healthcare system. Some of the reasons are in contrast to women, men are less concerned with their health and use health system less frequently30, leading to diagnosis at severe states. Regarding care, they would need to hire a formal caregiver or to be institutionalized, leading to an increase in the budget they spend on healthcare. In Brazil, on average, a family spends R$179.01 on healthcare31, and older adults’ expenditure on medicine represents 23% of their income30. Government programs that provide care are limited nowadays due to EC-95/2016, such as the “Melhorem Casa Program,” the Primary Care Strategy32, and the “Formação de cuidadores de idosos National Program33,” that make employees qualify for adult care support. Nevertheless, most of the older Brazilian adults do not receive formal care but informal care. For example, according to the National Health Survey 2013, 5.7% of older adults needing help did not receive any help, and 81.8% received informal help34. Yet, most older adults received help from an unpaid family member resident in the same household (62%)34, heavily concentrated among women35. Therefore, knowing the informal available caregivers and that women are more likely to provide care rather than men is necessary for implementing health education strategies and routine supervision, mainly at primary healthcare. One Brazilian study conducted in a social vulnerability area of São Carlos, São Paulo, showed that 60% of the older adults’ formal or informal caregivers aged ≥60 years were classified as frail/pre-frail35 or at risk of frailty36, similar to the international data showing that they are more likely to be pre-frail37. Yet, we have to consider that frailty is associated with caregiver burden38. Additionally, caregivers from high social vulnerability areas had lower education levels and received less emotional and material help to care39. Despite being frail themselves, around 20% of frail adults provided unpaid caregiver support to a frail older adult28. These data show that in some situations, even when the source of care is available, the provided care might be limited due to caregiver conditions. It highlights the necessity of supervising those older adults and caregivers continuously by the primary care team. However, with limited health funding, primary care access might not be universal and might not ensure access to frail older adults. In 2018, some primary care teams were dismissed by governments in some Brazilian states, such as the 239 primary care teams in Rio de Janeiro city, RJ. Then, the primary care range of actions was shortened. Our study has some limitations. First, our study has a cross-sectional design, which impedes pointing out the causal chain. Second, our sample is based on data from only one large city in Brazil, limiting the generalization to other Brazilian cities. Despite these limitations, our study has a strength methodology by using a selected sample derived from a large municipality in Brazil and having a protocol rigor, ensuring its internal validity. CONCLUSION The burden of frailty has become a challenge for public health systems because of its demands on long-term care. Only a small part of older adults have a lack of availability of care, but it is slightly higher among frail older adults. Public programs targeting this population are necessary to provide adequate care support. Focus on male older adults with a lack of availability of care should be due to a higher probability of having frailty/pre-frailty. REFERENCES 1. 1. Buckinx F, Rolland Y, Reginster JY, Ricour C, Petermans J, Bruyère O. Burden of frailty in the elderly population: Perspectives for a public health challenge. Arch Public Health. 2015;73(1):19. https://doi.org/10.1186%2Fs13690-015-0068-x Buckinx F Rolland Y Reginster JY Ricour C Petermans J Bruyère O Burden of frailty in the elderly population: Perspectives for a public health challenge Arch Public Health 2015 73 1 19 10.1186%2Fs13690-015-0068-x 2. 2. National Health Services. Global Health and Aging. Maryland: National Health Services; 2011. National Health Services Global Health and Aging Maryland National Health Services 2011 3. 3. Fried LP, Tangen CM, Walston J, Newman AB, Hirsch C, Gottdiener J, et al. Frailty in Older Adults: Evidence for a Phenotype. J Gerontol A Biol Sci Med Sci. 2001;56(3):M146-56. https://doi.org/10.1093/gerona/56.3.m146 Fried LP Tangen CM Walston J Newman AB Hirsch C Gottdiener J Frailty in Older Adults: Evidence for a Phenotype J Gerontol A Biol Sci Med Sci 2001 56 3 M146 56 10.1093/gerona/56.3.m146 4. 4. Siriwardhana DD, Hardoon S, Rait G, Weerasinghe MC, Walters KR. Prevalence of frailty and prefrailty among community-dwelling older adults in low-income and middle-income countries: A systematic review and meta-analysis. BMJ Open. 2018;8(3):e018195. https://doi.org/10.1136/bmjopen-2017-018195 Siriwardhana DD Hardoon S Rait G Weerasinghe MC Walters KR Prevalence of frailty and prefrailty among community-dwelling older adults in low-income and middle-income countries: A systematic review and meta-analysis BMJ Open 2018 8 3 e018195 10.1136/bmjopen-2017-018195 5. 5. Bieniek J, Wilczyński K, Szewieczek J. Fried frailty phenotype assessment components as applied to geriatric inpatients. Clin Interv Aging. 2016;11:453-9. https://doi.org/10.2147/cia.s101369 Bieniek J Wilczyński K Szewieczek J Fried frailty phenotype assessment components as applied to geriatric inpatients Clin Interv Aging 2016 11 453 9 10.2147/cia.s101369 6. 6. Ofori-Asenso R, Chin KL, Mazidi M, Zomer E, Ilomaki J, Zullo AR, et al. Global Incidence of Frailty and Prefrailty Among Community-Dwelling Older Adults: A Systematic Review and Meta-analysis. JAMA Netw Open. 2019;2(8):e198398. https://doi.org/10.1001/jamanetworkopen.2019.8398 Ofori-Asenso R Chin KL Mazidi M Zomer E Ilomaki J Zullo AR Global Incidence of Frailty and Prefrailty Among Community-Dwelling Older Adults: A Systematic Review and Meta-analysis JAMA Netw Open 2019 2 8 e198398 10.1001/jamanetworkopen.2019.8398 7. 7. Melo RC, Cipolli GC, Buarque GLA, Yassuda MS, Cesari M, Oudi Voshaar RC, et al. Prevalence of Frailty in Brazilian Older Adults: A Systematic Review and Meta-Analysis. J Nutr Health Aging. 2020;24(7):708-16. https://doi.org/10.1007/s12603-020-1398-0 Melo RC Cipolli GC Buarque GLA Yassuda MS Cesari M Oudi Voshaar RC Prevalence of Frailty in Brazilian Older Adults: A Systematic Review and Meta-Analysis J Nutr Health Aging 2020 24 7 708 16 10.1007/s12603-020-1398-0 8. 8. Andrade JM, Duarte YAO, Alves LC, Andrade FCD, Souza Junior PRB, Lima-Costa MF, et al. Frailty profile in Brazilian older adults: ELSI-Brazil. Rev Saúde Pública. 2018;52(suppl. 2):17s. https://doi.org/10.11606/S1518-8787.2018052000616 Andrade JM Duarte YAO Alves LC Andrade FCD Souza PRB Junior Lima-Costa MF Frailty profile in Brazilian older adults: ELSI-Brazil Rev Saúde Pública 2018 52 suppl. 2 17s 10.11606/S1518-8787.2018052000616 9. 9. Clegg A, Young J, Iliffe S, Rikkert MO, Rockwood K. Frailty in elderly people. Lancet. 2013;381(9868):752-62. https://doi.org/10.1016/s0140-6736(12)62167-9 Clegg A Young J Iliffe S Rikkert MO Rockwood K Frailty in elderly people Lancet 2013 381 9868 752 62 10.1016/s0140-6736(12)62167-9 10. 10. Chen S, Honda T, Narazaki K, Chen T, Kishimoto H, Kumagai S. Physical Frailty and Risk of Needing Long-Term Care in Community-Dwelling Older Adults: A 6-Year Prospective Study in Japan. J Nutr Heal Aging. 2019;23(9):856-61. https://doi.org/10.1007/s12603-019-1242-6 Chen S Honda T Narazaki K Chen T Kishimoto H Kumagai S Physical Frailty and Risk of Needing Long-Term Care in Community-Dwelling Older Adults: A 6-Year Prospective Study in Japan J Nutr Heal Aging 2019 23 9 856 61 10.1007/s12603-019-1242-6 11. 11. Hajek A, Bock JO, Saum KU, Matschinger H, Brenner H, Holleczek B, et al. Frailty and healthcare costs-longitudinal results of a prospective cohort study. Age Ageing. 2018;47(2):233-41. https://doi.org/10.1093/ageing/afx157 Hajek A Bock JO Saum KU Matschinger H Brenner H Holleczek B Frailty and healthcare costs-longitudinal results of a prospective cohort study Age Ageing 2018 47 2 233 41 10.1093/ageing/afx157 12. 12. Silveira Junior A. Economic Crisis, Class Struggle and Social Work in Brazil. Rev Katálysis. 2018;21(1):96-107. https://doi.org/10.1590/1982-02592018v21n1p96 Silveira A Junior Economic Crisis, Class Struggle and Social Work in Brazil Rev Katálysis 2018 21 1 96 107 10.1590/1982-02592018v21n1p96 13. 13. Paim J. Thirty years of the Unified Health System (SUS). Cien Saúde Colet. 2018;23(6):1723-8. https://doi.org/10.1590/1413-81232018236.09172018 Paim J Thirty years of the Unified Health System (SUS) Cien Saúde Colet 2018 23 6 1723 8 10.1590/1413-81232018236.09172018 14. 14. Garcez-Leme LE, Leme M. Costs of elderly health care in Brazil: challenges and strategies. MedicalExpress. 2014;1(1):3-8. https://doi.org/10.5935/MedicalExpress.2014.01.02 Garcez-Leme LE Leme M Costs of elderly health care in Brazil: challenges and strategies MedicalExpress 2014 1 1 3 8 10.5935/MedicalExpress.2014.01.02 15. 15. Lambotte D, De Donder L, Van Regenmortel S, Fret B, Dury S, Smetcoren AS, et al. Frailty differences in older adults’ use of informal and formal care. Arch Gerontol Geriatr. 2018;79:69-77. https://doi.org/10.1016/j.archger.2018.05.018 Lambotte D De Donder L Van Regenmortel S Fret B Dury S Smetcoren AS Frailty differences in older adults’ use of informal and formal care Arch Gerontol Geriatr 2018 79 69 77 10.1016/j.archger.2018.05.018 16. 16. Ryan LH, Smith J, Antonucci TC, Jackson JS. Cohort differences in the availability of informal caregivers: Are the Boomers at risk? Gerontologist. 2012;52(2):177-88. https://doi.org/10.1093%2Fgeront%2Fgnr142 Ryan LH Smith J Antonucci TC Jackson JS Cohort differences in the availability of informal caregivers: Are the Boomers at risk? Gerontologist 2012 52 2 177 88 10.1093%2Fgeront%2Fgnr142 17. 17. Johnson RW. The retirement project: In-Home Care for Frail Childless Adults Getting By With a Little Help From Their Friends? Washington, D.C.: The Urban Institute; 2006. Johnson RW The retirement project: In-Home Care for Frail Childless Adults Getting By With a Little Help From Their Friends? Washington, D.C. The Urban Institute 2006 18. 18. Feng Z. Childlessness and vulnerability of older people in China. Age Ageing. 2018;47(2):275-81. https://doi.org/10.1093%2Fageing%2Fafx137 Feng Z Childlessness and vulnerability of older people in China Age Ageing 2018 47 2 275 81 10.1093%2Fageing%2Fafx137 19. 19. Fret B, De Donder L, Lambotte D, Dury S, Van der Elst M, De Witte N, et al. Access to care of frail community-dwelling older adults in Belgium: a qualitative study. Prim Health Care Res Dev. 2019;20:e43. https://doi.org/10.1017/s1463423619000100 Fret B De Donder L Lambotte D Dury S Van der Elst M De Witte N Access to care of frail community-dwelling older adults in Belgium: a qualitative study Prim Health Care Res Dev 2019 20 e43 10.1017/s1463423619000100 20. 20. Oliveira DC, Neri AL, D’Elboux MJ. Lack of anticipated support for care for community-dwelling older adults. Rev Bras Enferm. 2016;69(3):530-7. https://doi.org/10.1590/0034-7167.2016690321i Oliveira DC Neri AL D’Elboux MJ Lack of anticipated support for care for community-dwelling older adults Rev Bras Enferm 2016 69 3 530 7 10.1590/0034-7167.2016690321i 21. 21. Torres JL, Dias RC, Ferreira FR, Macinko J, Lima-Costa MF. Functional performance and social relations among the elderly in Greater Metropolitan Belo Horizonte, Minas Gerais State, Brazil: a population-based epidemiological study. Cad Saúde Pública. 2014;30(5):1018-28. https://doi.org/10.1590/0102-311X00102013 Torres JL Dias RC Ferreira FR Macinko J Lima-Costa MF Functional performance and social relations among the elderly in Greater Metropolitan Belo Horizonte, Minas Gerais State, Brazil: a population-based epidemiological study Cad Saúde Pública 2014 30 5 1018 28 10.1590/0102-311X00102013 22. 22. Ricci NA, Pessoa GS, Ferriolli E, Dias RC, Perracini MR. Frailty and cardiovascular risk in community-dwelling elderly: A population-based study. Clin Interv Aging. 2014;9:1677-85. https://doi.org/10.2147/cia.s68642 Ricci NA Pessoa GS Ferriolli E Dias RC Perracini MR Frailty and cardiovascular risk in community-dwelling elderly: A population-based study Clin Interv Aging 2014 9 1677 85 10.2147/cia.s68642 23. 23. Brucki SMD, Nitrini R, Caramelli P, Bertolucci PHF, Okamoto IH. Suggestions for utilization of the mini-mental state examination in Brazil. Arq Neuropsiquiatr. 2003;61(3B):777-81. https://doi.org/10.1590/S0004-282X2003000500014 Brucki SMD Nitrini R Caramelli P Bertolucci PHF Okamoto IH Suggestions for utilization of the mini-mental state examination in Brazil Arq Neuropsiquiatr 2003 61 3B 777 81 10.1590/S0004-282X2003000500014 24. 24. Ferrucci L, Guralnik JM, Studenski S, Fried LP, Cutler GB, Walston JD. Designing Randomized, Controlled Trials Aimed at Preventing or Delaying Functional Decline and Disability in Frail, Older Persons: A Consensus Report. J Am Geriatr Soc. 2004;52(4):625-34. https://doi.org/10.1111/j.1532-5415.2004.52174.x Ferrucci L Guralnik JM Studenski S Fried LP Cutler GB Walston JD Designing Randomized, Controlled Trials Aimed at Preventing or Delaying Functional Decline and Disability in Frail, Older Persons: A Consensus Report J Am Geriatr Soc 2004 52 4 625 34 10.1111/j.1532-5415.2004.52174.x 25. 25. Lima-Costa MF, Cesar CC, Chor D, Proietti FA. Self-rated health compared with objectively measured health status as a tool for mortality risk screening in older adults: 10-year follow-up of the bambuí cohort study of aging. Am J Epidemiol. 2012;175(3):228-35. https://doi.org/10.1093/aje/kwr290 Lima-Costa MF Cesar CC Chor D Proietti FA Self-rated health compared with objectively measured health status as a tool for mortality risk screening in older adults: 10-year follow-up of the bambuí cohort study of aging Am J Epidemiol 2012 175 3 228 35 10.1093/aje/kwr290 26. 26. Carneiro JA, Cardoso RR, Durães MS, Guedes MCA, Santos FL, Costa FM, et al. Frailty in the elderly: prevalence and associated factors. Rev Bras Enferm. 2017;70(4):747-52. https://doi.org/10.1590/0034-7167-2016-0633 Carneiro JA Cardoso RR Durães MS Guedes MCA Santos FL Costa FM Frailty in the elderly: prevalence and associated factors Rev Bras Enferm 2017 70 4 747 52 10.1590/0034-7167-2016-0633 27. 27. Vonneilich N, Jöckel K-H, Erbel R, Klein J, Dragano N, Siegrist J, et al. The mediating effect of social relationships on the association between socioeconomic status and subjective health – results from the Heinz Nixdorf Recall cohort study. BMC Public Health. 2012;12:285. https://doi.org/10.1186/1471-2458-12-285 Vonneilich N Jöckel K-H Erbel R Klein J Dragano N Siegrist J The mediating effect of social relationships on the association between socioeconomic status and subjective health – results from the Heinz Nixdorf Recall cohort study BMC Public Health 2012 12 285 10.1186/1471-2458-12-285 28. 28. Lee DR, Santo EC, Lo JC, Ritterman Weintraub ML, Patton M, Gordon NP. Understanding functional and social risk characteristics of frail older adults: A cross-sectional survey study. BMC Fam Pract. 2018;19(1):170. https://doi.org/10.1186/s12875-018-0851-1 Lee DR Santo EC Lo JC Ritterman Weintraub ML Patton M Gordon NP Understanding functional and social risk characteristics of frail older adults: A cross-sectional survey study BMC Fam Pract 2018 19 1 170 10.1186/s12875-018-0851-1 29. 29. Torres JL, Lima-Costa MF, Marmot M, De Oliveira C. Wealth and disability in later life: The English Longitudinal Study of Ageing (ELSA). PLoS One. 2016;11(11):e0166825. https://doi.org/10.1371/journal.pone.0166825 Torres JL Lima-Costa MF Marmot M De Oliveira C Wealth and disability in later life: The English Longitudinal Study of Ageing (ELSA) PLoS One 2016 11 11 e0166825 10.1371/journal.pone.0166825 30. 30. Garcia LP, Sant’Anna AC, Magalhães LCG, Aurea A. Healthcare expenses of Brazilian families living in metropolitan areas: a composition and trends during the period from 1995 to 2009. Cien Saúde Colet. 2013;18(1):115-28. https://doi.org/10.1590/s1413-81232013000100013 Garcia LP Sant’Anna AC Magalhães LCG Aurea A Healthcare expenses of Brazilian families living in metropolitan areas: a composition and trends during the period from 1995 to 2009 Cien Saúde Colet 2013 18 1 115 28 10.1590/s1413-81232013000100013 31. 31. Lima-Costa MF, Barreto SM, Giatti L. Health status, physical functioning, health services utilization, and expenditures on medicines among Brazilian elderly: a descriptive study using data from the National Household Survey. Cad Saúde Pública. 2003;19(3):735-43. https://doi.org/10.1590/s0102-311x2003000300006 Lima-Costa MF Barreto SM Giatti L Health status, physical functioning, health services utilization, and expenditures on medicines among Brazilian elderly: a descriptive study using data from the National Household Survey Cad Saúde Pública 2003 19 3 735 43 10.1590/s0102-311x2003000300006 32. 32. Oliveira Neto A. Análise do programa Melhor em casa: um olhar sobre a atenção domiciliar no âmbito do Sistema Único de Saúde (SUS) [tese]. Brasília: Universidade de Brasília; 2016. Oliveira A Neto Análise do programa Melhor em casa: um olhar sobre a atenção domiciliar no âmbito do Sistema Único de Saúde (SUS) [tese] Brasília Universidade de Brasília 2016 33. 33. Brasil. Ministério de Estado da Previdência e Assistência Social e da Saúde. Portaria Interministerial No 5153. Brasília: Ministério de Estado da Previdência e Assistência Social e da Saúde; 1999. Brasil Ministério de Estado da Previdência e Assistência Social e da Saúde Portaria Interministerial No 5153 Brasília Ministério de Estado da Previdência e Assistência Social e da Saúde 1999 34. 34. Lima-Costa MF, Peixoto SV, Malta DC, Szwarcwald CL, Mambrini JVM. Informal and paid care for Brazilian older adults (National Health Survey, 2013). Rev Saúde Pública. 2017;51(Suppl. 1):6s. https://doi.org/10.1590/S1518-8787.2017051000013 Lima-Costa MF Peixoto SV Malta DC Szwarcwald CL Mambrini JVM Informal and paid care for Brazilian older adults (National Health Survey, 2013) Rev Saúde Pública 2017 51 Suppl. 1 6s 10.1590/S1518-8787.2017051000013 35. 35. Santos-Orlandi AA, Brito TRP, Ottaviani AC, Rossetti ES, Zazzetta MS, Pavarini SCI. Elderly who take care of elderly: a study on the Frailty Syndrome. Rev Bras Enferm. 2017;70(4):822-9. https://doi.org/10.1590/0034-7167-2016-0474 Santos-Orlandi AA Brito TRP Ottaviani AC Rossetti ES Zazzetta MS Pavarini SCI Elderly who take care of elderly: a study on the Frailty Syndrome Rev Bras Enferm 2017 70 4 822 9 10.1590/0034-7167-2016-0474 36. 36. Potier F, Degryse J, Aubouy G, Henrard S, Bihin B, Debacq-Chainiaux F, et al. Spousal Caregiving Is Associated with an Increased Risk of Frailty: A Case-Control Study. J Frailty Aging. 2018;7(3):170-5. https://doi.org/10.14283/jfa.2018.11 Potier F Degryse J Aubouy G Henrard S Bihin B Debacq-Chainiaux F Spousal Caregiving Is Associated with an Increased Risk of Frailty: A Case-Control Study J Frailty Aging 2018 7 3 170 5 10.14283/jfa.2018.11 37. 37. Potier F, Degryse J, Bihin B, Debacq-Chainiaux F, Charlet-Renard C, Martens H, et al. Health and frailty among older spousal caregivers: an observational cohort study in Belgium. BMC Geriatr. 2018;18(1):291. https://doi.org/10.1186/s12877-018-0980-3 Potier F Degryse J Bihin B Debacq-Chainiaux F Charlet-Renard C Martens H Health and frailty among older spousal caregivers: an observational cohort study in Belgium BMC Geriatr 2018 18 1 291 10.1186/s12877-018-0980-3 38. 38. Ringer TJ, Hazzan AA, Kennedy CC, Karampatos S, Patterson C, Marr S, et al. Care recipients’ physical frailty is independently associated with subjective burden in informal caregivers in the community setting: a cross-sectional study. BMC Geriatr. 2016;16(1):186. https://doi.org/10.1186/s12877-016-0355-6 Ringer TJ Hazzan AA Kennedy CC Karampatos S Patterson C Marr S Care recipients’ physical frailty is independently associated with subjective burden in informal caregivers in the community setting: a cross-sectional study BMC Geriatr 2016 16 1 186 10.1186/s12877-016-0355-6 39. 39. Pavarini SCI, Neri AL, Brigola AG, Ottaviani AC, Souza ÉN, Rossetti ES, et al. Elderly caregivers living in urban, rural and high social vulnerability contexts. Rev Esc Enferm USP. 2017;51:e03254. https://doi.org/10.1590/S1980-220X2016040103254 Pavarini SCI Neri AL Brigola AG Ottaviani AC Souza ÉN Rossetti ES Elderly caregivers living in urban, rural and high social vulnerability contexts Rev Esc Enferm USP 2017 51 e03254 10.1590/S1980-220X2016040103254 Funding: Brazilian National Research Council, Coordination of Improvement of Higher Education Personnel, and the Minas Gerais State Research Foundation.