The State Of Frailty Research In Arabic-Speaking Countries: A Scoping Review

INTRODUCTION

In developed countries, frailty—a state in which an individual has a higher risk of adverse health effects than others of the same age or exposure—is increasingly acknowledged.¹ It is a clinical disorder characterized by a loss of function in one or more physical, psychological, or social areas. Therefore, experts conceptualize frail older people as complex systems teetering on the brink of breakdown or failure.² Frailty is strongly associated with advanced age, comorbidities, a low socioeconomic position, and lifestyle risk factors.^3-5 In addition, it predicts surgical complications, falls, hospitalization, and death. ^6,7 The impact and burden of frailty, its significance in clinical practice, and the importance of frailty management for older individuals' health and well-being must be considered.⁸

The global prevalence of frailty is unknown, and little is known about frailty prevalence and the nature of frailty in different ethnic groups, as frailty research has been conducted predominantly in high-income countries. The concept of frailty has received considerable attention in developed nations (e.g., Europe and North America), as have effective methodologies for diagnosing and quantifying frailty in clinical practice.^9-11 In addition, the incorporation of interventions to reduce the impact of frailty on individual health and the burden on the healthcare system is evolving rapidly in these nations.^12-15 However, this may not be true in the Arabic world.

Over 422 million people live in Arabic-speaking countries (ASCs) in the Middle East and North Africa, including Egypt, Saudi Arabia, Kuwait, the United Arab Emirates, Lebanon, Yemen, Palestine, Algeria, Libya, Bahrain, Iraq, Morocco, Qatar, Sudan, Syria, and Tunisia.¹⁶ These countries, like more developed ones, are experiencing an increase in the number and proportion of older adults due to an aging population. Research has established a link between frailty as an age-related syndrome and environmental factors such as low education and inadequate nutrition, resulting in a potentially higher prevalence in low- to middle-income countries like those listed above compared to developed nations. ¹⁷ However, frailty research may be underdeveloped in these countries, and in order to offer adequate care for frail older people in this part of the world, it is important to understand what is known about frailty in ASCs.

No reviews of research on ASC frailty have been published, according to the authors' knowledge. Thus, we conducted a scoping review to evaluate, map, and consolidate the ASC's published literature on frailty. The review explored two main areas: 1) the reported findings on frailty and its related domains (e.g., prevalence, impact of gender, comorbidities, or other health and social conditions) among individuals aged 60 years and older residing in ASCs; and 2) the utilization of frailty tools to identify and measure frailty in older adults within ASCs. We believe the findings of this review will serve as a foundation for future research on frailty in ASCs.

 METHODS

The Joanna Briggs Institute (JBI) methodology for scoping reviews was used for this research.¹⁸ There was no patient or public participation in the design, conduction, reporting, or dissemination of this research. A comprehensive protocol has previously been published¹⁹ and is summarized below.

Search strategy

A health research librarian from Dalhousie University, Halifax, Canada, helped the first author (AA) create the search protocol. The strategy followed the Peer Review Electronic Search Strategies (PRESS) guidelines to generate keywords including frailty, vulnerability, older adults, frailty measurement, and Arab (global, language, country). ²⁰ Experimental, quasi-experimental, randomized, non-randomized, pre-post, and interrupted time-series studies were searched. Additionally, descriptive, analytical, case-study, and cross-sectional observational studies were considered.

Selection criteria

To be included, an article had to meet three criteria:  1) examine the concept of frailty (as previously defined); 2) include participants at least 60 years old living in ASCs; and 3) participants must have been assessed for frailty. We contacted authors directly when we needed additional information about the eligibility of an article. A native Arabic-speaking reviewer (AA) reviewed journal articles written in Arabic or bilingual articles (Arabic/English).  

Information sources

The academic databases searched were MEDLINE (Ovid), Embase, CINAHL, PsycINFO, and Scopus. Middle Eastern journals and websites were searched using Google Scholar. We searched the Arabic/English Journal of University Studies for Inclusive Research (USRIJ), Electronic Interdisciplinary Miscellaneous Journal (EIMJ), Zaytuna College Journal, King Saud University Press, and Nile Scientific Journal.

Study selection

To ensure each article met the inclusion criteria, two review team members (AA and SJK) independently screened the title and abstracts followed by the full text of the articles. Any disagreements between the two reviewers were discussed, and a consensus was reached.

Data handling

The search results from each database were uploaded into Covidence,²¹ where duplicates were removed. AA and SJK reviewed the articles independently and then discussed the contradicting results and their relevance to the research. After screening and selecting the articles, both reviewers independently completed a data extraction form for each study that recorded the study's authors, publication year, purpose, design, country, population characteristics, setting(s), frailty measurement(s), tool descriptions, outcomes, and most significant findings. AA and SJK discussed the data they had gathered and reached a consensus regarding any discrepancies.

 RESULTS

The database search yielded 201 publications for examination (Figure 1). CINAHL, Medline, Embase, PsycInfo, Scopus, and Google Scholar identified 19, 12, 110, 6, 53, and 1 article respectively. Fifty-five duplicate documents were removed by Covidence. AA and SJK reviewed the titles and abstracts of the remaining 146 publications using the inclusion criteria. Ninety seven of the 146 articles were excluded due to not meeting eligibility criteria (with the reason(s) given). The full-text review rejected 22 publications that did not match all inclusion criteria or were inaccessible. AA and SJK selected 27 English publications to be included. No Arabic articles were found.

Figure 1: Article search and screening flowchart. From:  Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021;372:n71. doi: 10.1136/bmj.n71

In most articles (44.4%) frailty was measured as a participant’s characteristic. For example, out of the included articles, 4 articles measured frailty to predict adverse health outcomes such as unplanned hospitalization and mortality,³⁰ falls,³⁸ and post-surgery complications.^25,47 In Lebanon, 4 studies focused on the association between frailty and malnutrition status of the participants ²⁹ or the association of frailty with other health conditions.^28,31,32

Characteristics of included studies.

Table 1 summarizes the characteristics of 27 studies included in this review. The review findings identified that most articles (56%; n=15) were published from 2020 onward. Twenty-one (77.7%) of the studies were cross-sectional by design, while four studies were a cohort design,^25,30,38,47 one was a case-control study,⁴⁶ and one was retrospective.⁴⁰ The number of participants per study ranged from 47 to 1200. Most of the studies, 59.2% (n=16), were conducted at outpatient clinics or hospitals, 29.6% (n= 8) in the community, and 11.1% (n=3) at senior homes/long-term care facilities. The greatest number of studies originated in Egypt (44.4%; n=12), followed by Saudi Arabia and Lebanon (22.2%; n=6 each), then Tunisia (7.4%; n=2) and Jordan (3.7%; n=1). The mean age of participants across the studies ranged from 60 to 89 years. In most studies (n= 15) the number of males and females is nearly equal; however, the number of males is nearly double that of females in studies conducted mainly in Saudi Arabia(n=4) ^{22,26,27,33 42} and one study from Egypt ⁴⁷.

Table 1: Descriptive characteristics of articles included

T=total; M=male; F=female; Inc=included Exc=excluded; EF=ejection fraction; NA=not applicable; MMSE=mini-mental state examination; DM=diabetes mellitus.

Frailty measurement characteristics of included articles

Table 2 summarizes the characteristics of frailty measurement tools reported in the included articles. Overall, 10 frailty measurement tools were used across all studies. The most commonly used measures were the Fried Phenotype (FP) (n=8)^{22,23,26,33,36,42,43,47} followed by the Study of Osteoporotic Fractures (SOF- FI) (n=6).^{28,29,31,32,39,40} and the Clinical Frailty Scale (CFS) (n=3).^41,44,45 Two articles used two measures  to identify frailty,^29,34,46 one study used the Study of Osteoporotic Fractures (SOF) and the Frailty Index (FI)²⁹, one study compared FP to FI,³⁴  and the other study used the Comprehensive Geriatric Assessment (CGA)  and the FP.⁴⁶ Other measurements used in conjunction with frailty measurements included a comprehensive geriatric assessment (n=7)^{23,34,35,38,39,41,46} and nutritional status using the Mini Nutritional Assessment (n=5).^{28,29,31,32,33}. Physical performance (e.g., grip strength and Time Up and Go) was measured in five studies.^{24,26,27,38,45.} 

Table 2: Frailty measurement characteristics of included articles

CHF=congestive heart failure; SHA mFI=Canadian Study of Health and Aging modified Frailty Index; CGA= Comprehensive geriatric assessment; SOF=Study of Osteoporotic Fractures; TFI=Tillburg frailty Indicator; ISAR=Identification of Senior at Risk; ED=emergency department; FP=Fried phenotype; FI=frailty Index; SEGAm= Short Emergency Geriatric Assessment; GFI=the Groningen frailty indicator; CFS=clinical frailty scale; ADL=activity of daily living.

Factors associated to frailty

Table 3 summarizes the studies’ objective(s), and which factors the studies assessed (e.g., demographic, social, or health conditions). According to the measurement tools utilized in the studies, the prevalence of frailty and prefrailty (in which one or two criteria are present) among participants ranged between 21.4% to 37.0% and 30.0% to 47.3%, respectively. These findings suggest a high prevalence of pre-frailty and frailty among Arabic populations compared to other populations from different nations (e.g., Western countries and Japan).^49-53

Table 3: Factors associated/ investigated/ or corelated to frailty

P=factors related to the population characteristic; D=factors related to disease/ illness; S=factors related to social issues; CHF=congestive heart failure; EF=ejection fraction; BMD=body mass density; NA=not applicable; m-FI= modified frailty index; TFI=Tillburg frailty Indicator; BMI=body mass index; ADL=activity of daily living; IADL= instrumental activity of daily living; ER=emergency room; MUC= mid upper arm circumference; MCC= mid calf circumference; Qol=quality of life, DM=diabetes mellitus; UI=urinary infection; IGF-=the IGF-1 including IGF-1 and IGF-2 are single chain polypeptide;  MAC=mid arm circumference, CFS=clinical frailty scale, ASA-PS=American society of anesthesiologists physical status, WHO/ ECOG=World Health Organization/ Eastern Cooperative Oncology Group; MMSE=mini-mental stat examination; TUG=time up and go; LMD=Lebanese Mediterranean diet.

 In brief, four studies conducted in Saudi Arabia focused on assessing the prevalence of frailty^22,23 or analyzed psychometric properties of frailty measures.^26,27 Of the 6 studies conducted in Lebanon, only one assessed the psychometric properties of a frailty scale.³⁷ Moreover, three publications evaluated the feasibility, effectiveness, and reliability of three Arabic versions of frailty measures in their respective communities.^26,27,37Also, four articles used frailty as a predictor of adverse health outcomes (i.e., unplanned hospitalization and death,³⁰ falls,^38, and postoperative surgery complications)^28,50 and found increased adverse outcomes in frail patients compared to robust patients.

Of the 27 articles, nine studies investigated the association between frailty and other domains (medical, geriatric, social conditions, and demographic).^{22,23,29,33,34,36,41,42,48} Three papers, for example, examined the relationship between frailty and age and sex.^22,23,37 They found an increase in the prevalence of frailty was associated with advanced age (≥80) and that there was a greater prevalence of pre-frailty in females.^22,23 Several studies evaluated the relationship between frailty and other factors/conditions. For example, one study found that vitamin C levels are lower in frail elderly patients with type 2 diabetes mellitus.⁴⁶ Another study reported that higher levels of the pro-inflammatory cytokines, TNF-α, CRP, and especially IL-8 are associated with the development of frailty in Tunisian older adults.³⁴ In addition, one study found an association between low insulin-like growth factor-1 (IGF-1) and an increased risk of being frail in older Egyptian males.³⁹ Two studies investigated factors associated with a healthy life (e.g. diet, sleep). One study found that higher frailty is associated with poor sleep quality in older adults in Saudi Arabia.⁴² A Lebanese study found that greater adherence to the Lebanese Mediterranean diet (LMD) was associated with a decreased prevalence of frailty.⁴⁸ Other studies investigated the association between medical conditions and frailty in older adults. For example, the associations between congestive heart failure (CHF) and sarcopenia,²⁴ urinary incontinence (UI) and the quality of life among frail older women.⁴³ It was found that higher frailty scores are associated with the presence of any one of these medical conditions.

Of all the studies, one study investigated the use of technology to identify frailty.⁴⁴ Specifically, this study assessed a smartphone app’s usability and ability to identify older adults with geriatric conditions. The findings of this study shows that the use of such an instrument could help general practitioners provide pre-comprehensive Geriatric Assessment evaluations in areas with limited access to formal geriatric healthcare services, thereby overcoming some obstacles to identifying geriatric syndromes such as frailty.

 DISCUSSION

Our scoping review revealed that the prevalence of frailty among individuals aged 60 and above in ASCs differs depending on the study's setting and possibly the assessment tool employed. The prevalence of frailty in hospital settings varied from 12.7% to 51% and in the community context, the prevalence of frailty ranged from 28.3% to 47.3%, while in seniors' homes, the prevalence was 22.4%. Frailty increased with age, sex (female), comorbidities, sociodemographic factors (low education, living alone, and poverty), polypharmacy, and cognitive impairments. Frail people have twice as many health and functional impairments as robust people. This outcome matches other international frailty research. For example, a Japanese study utilizing the same frailty measurement tools used in several of the studies included in this review indicated that the prevalence of frailty was 1.9%, 3.8%, 10.0%, 20.4%, and 35.1% for those aged 65–69, 70–74, 75–79, 80–84, and ≥85 years, respectively.⁴⁹ Another systematic review of the prevalence of frailty in Latin America and Caribbean countries indicated that frailty prevalence was 19.6% among community dwelling older adults.⁵⁰ An additional systematic review revealed that the overall prevalence of frailty was 10.7%  among older adults in Europe and North America where the  prevalence of frailty among community-dwelling older adults varied from 4.0% to 59.1%.⁵¹ Overall, the prevalence of frailty in ASCs appears similar to what has been reported in developed and developing countries.

Based on the included studies, compared to developed nations, the average age of the ASC population to develop pre- and frailty is younger. To illustrate, the average age of participants in the studies was 60–89 years, with a few participants being over 75 years old. This may be attributed to frailty-risk factors in this region. For instance, a higher rate of medical (comorbidity) conditions and social (poor education or poverty) factors may increase frailty and mortality.⁵² Other demographic variables that may influence the prevalence of frailty in ASCs include sex (females in ASCs may be less likely to participate in research for cultural reasons), indicating a higher proportion or a greater relative risk of frailty among frail females in ASCs.

Furthermore, pre-frailty prevalence in ASCs also varied based on the study’s setting. In hospital settings it ranged from 12.7%–51%, 21.4%–36.4% in the community, and 22.6% in the senior home. These results suggest that identifying a subset at high risk of frailty is slightly greater in ASCs than in non-Arabic nations. ^22,25,28 A systematic review found 4.1% of older persons in 10 European nations were frail, whereas 37.4% were prefrail. ⁵² This shows that future increases in frailty prevalence among older ASC residents are likely and raises the question of whether the average lifespan variations between ASC residents and other nations may be related to frailty and pre-frailty levels. It is commonly known that older people in ASCs live with their siblings or relatives rather than in retirement centres, resulting in fewer LTCFs than in developed nations, which could lead to inadequate care for this subpopulation. Thus, screening and prevention programs may help healthcare institutions identify at-risk patients and provide appropriate care.

Advanced age, female sex, greater comorbidities, cognitive impairment, poor nutritional status, and loneliness are social and medical factors that are positively correlated with frailty levels in ASCs, consistent with previous research involving non-ASCs. These findings are consistent with previous research involving non-ASCs. In a Chinese study, for instance, advanced age, gender, and ethnicity were substantially associated with higher levels of frailty.⁵³ Additionally, advanced age, greater than 80 years, and female gender were risk factors for increasing frailty among Indian seniors (83.4%).⁵⁴ Data from a meta-analysis also showed that the prevalence of physical frailty was higher among females in 62 countries.⁵⁵ A study among older adults in the United States found that frailty was more prevalent at older ages, among women, racial and ethnic minorities, those in supportive residential settings, and persons of lower income. ⁵⁶ Knowledge of the complexity of frailty's determinants can facilitate the development of measures for prevention and early intervention, thereby enhancing the quality of life for this subpopulation.

Lastly, this review suggests that frailty in ASCs is highly understudied compared to developed nations. The vast majority of articles were published after the year 2020, which suggests that frailty research uptake in ASCs was slower than in more developed countries. Therefore, research on frailty has only recently begun in ASCs, and/or frailty could be an unnoticed or under-researched topic in this part of the world. This lack of data, information, and records regarding the number and conditions of older adults living with frailty in ASCs may pose a challenge when caring for this subpopulation or during a public health emergency such as the COVID-19 pandemic. ⁵⁷

Limitations and strengths

The study employed a robust article search strategy. There were no systematic or comprehensive searches for frailty research in this region. Thus, this review is the first to examine frailty in Arabic countries, according to the reviewers. Reviewers examined English and Arabic journal sites for frailty articles, which is another strength.

This may be more of a challenge than a limitation, but the lack of research on frailty, its impact on older people, and its assessment techniques makes it difficult to compare differences in the concept, measurement, and impact of frailty between ASCs and other nations. As with most frailty research globally, the reviewers only included participants 60 and older; hence, the study did not include studies on frailty in lower age groups (<60). The primary limitation with this review is that a patient/public member was not engaged in the process. Based on language barriers and education levels it deemed not feasible.

Conclusions

This scoping research found high levels of frailty and prefrailty in ASCs, which related to geriatric factors and health problems. Most research examined the relationship between frailty and health concerns like CHF, urine incontinence, sleep quality, and diabetes in older persons. Cross-sectional and contemporary studies were predominant. Besides Comprehensive Geriatric Assessments (CGAs), research from ASCs utilized FP, FI, and SOF-FI tests to assess frailty. No studies examined frailty management or improvement. However, frailty has a huge influence on individuals, communities, and economies; therefore, future studies should focus on its occurrence, impact, and management to improve research and care for frail older adults in ASCs.

Evidence from the studies

• Frailty appears to be neglected in ASCs, and research into it is progressing slowly.

• Most studies were cross-sectional and lasted almost a year, so more longitudinal observational studies are needed to assess frailty and pre-frailty prevalence and frail patients' mortality and morbidity.
• No research has examined the etiology, pathophysiology, or genetics of frailty in older persons in ASCs. However, frailty studies will benefit from disparities between industrialized and developing nations.
• No studies adjusted intervention(s) or treatment strategies for frailty in ASCs.

• Due to the high prevalence of frailty and pre-frailty and the lack of research on the feasibility and reliability of screening instruments, Arabic frailty assessment methods must be studied. Translating tools into Arabic may work.
• ASC healthcare systems must network and collaborate with developed-country frailty researchers to devise a crisis management approach for frail older individuals.