geriatrics

Article
Frailty and Associated Factors among the Elderly in Vietnam:
A Cross-Sectional Study
Trung Quoc Hieu Huynh 1, * , Thi Lan Anh Pham 2 , Van Tam Vo 2 , Ha Ngoc The Than 3 and Tan Van Nguyen 3

1 Department of Graduate Training, University of Medicine and Pharmacy at Ho Chi Minh City,
Ho Chi Minh City 700000, Vietnam
2 Faculty of Public Health, University of Medicine and Pharmacy at Ho Chi Minh City,
Ho Chi Minh City 700000, Vietnam
3 Department of Geriatrics & Gerontology, University of Medicine and Pharmacy at Ho Chi Minh City,
Ho Chi Minh City 700000, Vietnam
* Correspondence: [email protected]; Tel.: +84-973-555-567

Abstract: Background: Frailty syndrome is common among older people and can lead to various
adverse consequences such as falls, cognitive decline, disability, dependent living, increased mortality,
excessive drug use, and prolonged hospital stays. Objectives: This research determined the prevalence
of frailty and associated factors among older adults in Vietnam. Methods: A cross-sectional study was
conducted on 584 older adults across five Ho Chi Minh City wards from November 2020 to January
2021. Based on the modified Fried frailty scale, the participants were divided into three categories:
robust, pre-frail, and frail. A chi-square test (or Fisher’s test) examined the relationship between
frailty categories and other variables. Multivariable logistic regression used variates with a cut-off
of p ≤ 0.05 in the univariate analysis. Results: The prevalence rates of frailty and pre-frailty were
19% and 64%, respectively. The most common frailty component was weak grip strength (63.9%),
followed by slowness (36.1%), weight loss (21.6%), low physical activity (19.5%), and exhaustion
(18.5%). In addition, the prevalence of frailty was significantly associated with age, BMI levels, living
Citation: Huynh, T.Q.H.; Pham, alone, and sarcopenia. Conclusion: The community’s prevalence of frailty among older adults is high.
T.L.A.; Vo, V.T.; Than, H.N.T.; Frailty can lead to many adverse consequences for the elderly. As there were some modifiable factors
Nguyen, T.V. Frailty and Associated associated with frailty, it should be assessed in older people through community-based healthcare
Factors among the Elderly in programs for early diagnosis and management.
Vietnam: A Cross-Sectional Study.
Geriatrics 2022, 7, 85. https://doi.org/
Keywords: aging; frailty; older adults; Vietnam; community; functional decline
10.3390/geriatrics7040085

Academic Editor: Victoria L. Keevil

Received: 12 July 2022

1. Introduction
Accepted: 18 August 2022
Published: 20 August 2022 According to the United Nations, older adults are people who are aged 60 years or
older. In recent years, the number of older adults worldwide has increased unprecedentedly.
Publisher’s Note: MDPI stays neutral
The United Nations estimates that the number of people aged 60 and over is expected to
with regard to jurisdictional claims in
increase by 56%, from 901,000,000 to 1,400,000,000, between 2015 and 2030. The global
published maps and institutional affil-
population is aging rapidly. Currently, 566 million people are ≥65 years old worldwide,
iations.
with an estimated increase to 1.5 billion by 2050. According to United Nations estimates,
over the next 15 years, the number of older adults will increase the fastest in the U.S., Latin
America, and the Caribbean (71%), followed by Asia (66%), Africa (64%), Oceania (47%),
Copyright: © 2022 by the authors. North America (41%), and Europe (23%) [1].
Licensee MDPI, Basel, Switzerland. Vietnam is one of the countries with the fastest population aging in the world. People
This article is an open access article aged 60 and over accounted for 11.9% of the total population in 2019; by 2050, this number
distributed under the terms and will increase to more than 25%. By 2036, Vietnam will enter a period of an aging population,
conditions of the Creative Commons transitioning from an “aging” society to an “aged” society. This demographic change is
Attribution (CC BY) license (https:// expected to occur in Vietnam not only due to a decrease in mortality and an increase in
creativecommons.org/licenses/by/ life expectancy but also primarily due to a sharp decrease in birth rates. The declining
4.0/).

Geriatrics 2022, 7, 85. https://doi.org/10.3390/geriatrics7040085 https://www.mdpi.com/journal/geriatrics

Geriatrics 2022, 7, 85 2 of 9

birth rate in the past decades has significantly impacted Vietnam’s population structure,
accelerating the population’s aging rate [2].
Frailty syndrome, a geriatric syndrome, occurs due to the accumulation of multiple
functional impairments [3]. The prevalence of frailty in the community ranges from
4% to 59%, while it ranges from 19% to 76% in nursing homes [4]. In Vietnam, The
prevalence of frailty in the community ranges from 11.2% to 21.7%, and from 18.5% to
54.9% in hospitalized patients [5–11]. Since introducing the concept of frailty, gerontologists
have studied many assessment tools such as the Fried scale, the Frailty Index (FI), and
the PRISMA-7 questionnaire [12]. Among the assessment tools, the Fried scale is the
gold standard used in epidemiological studies and predicts clinical outcomes such as
re-hospitalization, mortality, falls, and fractures [13,14]. Frailty can lead to many adverse
consequences for older adults, such as falls, cognitive decline, disability, dependent living,
increased mortality, excessive drug use, and prolonged hospital stays. Moreover, frailty is
also an important prognostic sign that can be used to help prevent worsening conditions.
Therefore, screening, early detection, and planning intervention for frailty in older people
are fundamental in geriatric medicine. However, there have not been many studies on this
issue in Vietnam. The purpose of this study was to provide data and contribute to scientific
knowledge of the prevalence of frailty and associated factors in community-dwelling older
adults in Vietnam by the Fried frailty scale.

2. Materials and Method

2.1. Sample Size
The sample size was determined using a single population proportion formula:

n = Z2 1-α/2 × p(1 − p)/d2 × DE (1)

with n = the required sample size, p = proportion of frail patients, and d = precision
(assumed as 0.05), DE (design effect) = 2 (cluster sampling design). Taking references from
reports from AT Nguyen (2019) [15], we estimated that the proportion of patients achieving
frail would be around 21.7%. Therefore, the sample size for this study was calculated to be
at least 524 participants.

2.2. Participants
The participants were recruited via health check programs for all older adult patients
at the ward health stations, which are homogenous in terms of demographic, social, and
geographical characteristics. This is an annual health check-up program for the older adult
living in District 9, Ho Chi Minh City. We collaborated randomly with five wards of District
9. Participants were recruited through the persons in charge of community care centers of
the ward health station. Therefore, the number of samples was evenly distributed among
the wards, with the specific sample number being about 120 participants.
The inclusion criteria were as follows: (1) aged 60 or older; (2) mentally alert and able
to listen and give interviews; and (3) able to speak or understand the Vietnamese language.
Participants were not included in this study if they were unable to perform the specific
functional test (bedridden people, blind, hearing loss) or unable to communicate (severe
cognitive impairment) or those with motor impairment resulting from acute diseases such
as recent stroke, coronary heart disease, and cardiomyopathy or with acute musculoskeletal
diseases or orthopedic diseases.

2.3. Study Design

From November 2020 to January 2021, we conducted a cross-sectional study in Dis-
trict 9, Ho Chi Minh City, Vietnam. Data was collected using interviewer-structured ques-
tionnaires on common characteristics (age, gender, education level, and living situation)
from participants and performed functional tests [16,17].
The primary exposure variables included the following: Participants’ comorbid condi-
tions were collected based on medical records (chronic diseases, medications, the Charlson
Geriatrics 2022, 7, 85 3 of 9

Comorbidity Index, current smoking, and BMI levels). Polypharmacy was judged based
on daily prescriptions (defined as five or more prescribed medications) [18,19]. In ad-
dition, paramedics conducted data that included five well-trained geriatric nurses and
nursing students.
Written informed consent was obtained from all participants.

2.4. Outcome Assessment

The modified Fried frailty scale [12] determined the level of frailty, including the
following five criteria:
– Weight loss of more than 5% or 4.5 kg compared to weight in the last 12 months.
– Exhaustion: Two questions in the Centre for Epidemiologic Studies Depression Scale
were used: “I felt that everything I did was an effort last week” and “I could not
get going last week.” People were defined as having exhaustion if they answered
“frequently” or “always” at least once [12].
– Low physical activity was evaluated using the International Physical Activity Question-
naire—Short Form (IPAQ-SF) [20]. The cut-off values were stratified by sex (women,
<270 Kcals/week; men, <383 Kcals/week).
– Slowness: We used a 6 m walking time to assess physical performance, with low
physical performance defined as a speed below 1 m/s [14,21,22].
– Weakness was evaluated based on handgrip strength using a Jamar hydraulic dy-
namometer (model J00105; Lafayette Instrument, Lafayette, IN, USA). The arm was
placed on the side of the body, and a 90◦ folding elbow held the force meter. The mea-
surements were repeated three times, with the most significant value of the forehand
used in the analysis. Weakness was defined as a handgrip strength of less than 14 kg
and 28 kg in women and men, respectively [14].
Subjects who met three criteria or more were classified as frail, and those who met
from zero to two criteria were classified as non-frail (including pre-frail and robust) [14].
Sarcopenia assessment: We assessed sarcopenia according to the revised version of
the Asian Working Group on Sarcopenia 2019 consensus (AWGS), which recommends
evaluating muscle strength, muscle quantity, and physical performance while considering
ethnic differences [21].
The skeletal muscle mass index is calculated by dividing the appendicular skeletal
muscle mass (kg) by the square of the height (m2 ). Appendicular skeletal muscle mass is cal-
culated based on Bioelectrical impedance analysis (BIA) performed using an Inbody device
(Inbody 770, multi-frequency segmental body composition analyzer; Inbody, Seoul, Korea).

2.5. Statistical Analysis

Frequencies and percentages were used for the categorical variables to describe the
participants, and means and standard deviations were used for the continuous variables.
Chi-square tests (or Fisher’s tests) examined the relationship between frailty categories and
the categorical demographic and exposure variables. In the bivariate analyses, odds ratios
(ORs) with a 95% CI were generated using logistic regression. The results were used to
evaluate the relationship between frailty status and the characteristics of the participants.
Multivariable logistic regression was performed using a stepwise backward selection
procedure with a cut-off of p ≤ 0.05 in the univariate analysis to identify factors associated
with frailty status.

3. Result
3.1. Demographics and Baseline Characteristics
A total of 584 participants (175 men and 409 women) were eligible for this study.
The baseline characteristics of 584 participants are shown in Table 1. The mean age was
69.57 ± 7.25 years, consisting of 55% being aged 60–69, 34.3% being 70–79, and 10.7%
being 80 or older. The majority of the participants had normal BMI levels (41.4%). Most
participants (74.3%) lived with a relative. Nearly all of them (90.92%) did not smoke.
Geriatrics 2022, 7, 85 4 of 9

Overall, the rate of participants having sarcopenia was 48.6%, and 5% had severe sarcopenia.
The most prevalent comorbidities were hypertension and dyslipidemia. This study also
indicated that 47.8% had Charlson Comorbidity Index from 1 to 2 points, and 12.67% of the
participants received polypharmacy.

Table 1. Participant characteristics (n = 584).

Participants’ Characteristics n (%)

Sex
Male 175 (30)
Female 409 (70)
Age 69.57 ± 7.25 (60–92) *
60–69 years old 321 (55)
70–79 years old 200 (34.3)
80 years or older 63 (10.7)
Living situation
Alone 150 (25.7)
With relatives 434 (74.3)
BMI levels
Underweight (<18.5 kg/m2 ) 49 (8.4)
Normal (18.5–22.9 kg/m2 ) 242 (41.4)
Overweight (23–24.9 kg/m2 ) 117 (20)
Obese (>25 kg/m2 ) 176 (30.1)
Current smoking
Yes 53 (9.1)
No 531 (90.92)
Sarcopenia
Non-sarcopenia 271 (46.4)
Sarcopenia 284 (48.6)
Severe sarcopenia 29 (5)
Comorbidity
Hypertension 306 (52.4)
Dyslipidemia 217 (37.2)
Diabetes 105 (18)
Chronic kidney disease 38 (6.5)
Charlson Comorbidity Index
0 point 177 (30.3)
1–2 points 279 (47.8)
≥3 points 128 (21.9)
Polypharmacy (≥5 drugs) 74 (12.67)
* Mean ± standard deviation (minimum-maximum).

Table 2 shows that among the 584 participants involved in the study, 99 (17%) were
robust, 374 (64%) participants pre-frail, and 111 (19%) were frail. The most common frailty
component was weakness (63.9%), followed by slowness (36.1), weight loss (21.6%), low
physical activity (19.5%), and exhaustion (18.5%).

Table 2. Prevalence of frailty status and components (n = 584).

Frailty Status
Characteristics
n % Robust Pre-Frail Frail
Frailty status 584 100 99 (17) 374 (64) 111 (19)
Slowness 211 36.1
Weakness 373 63.9
Low physical activity 114 19.5
Exhaustion 108 18.5
Weight loss 126 21.6
Geriatrics 2022, 7, 85 5 of 9

3.2. Factors Associated with Frailty

Table 3 presents the final model from the multivariable analysis. The model re-
vealed that age, BMI levels, living situation, and sarcopenia were predictors of frailty.
Participants who were older (aOR = 2.04, 95% aCI = 1.07–391), underweight (aOR = 2.21,
95% aCI = 1.06–4.60), living alone (aOR = 1.64, 95% aCI = 1.04–2.61), or had sarcopenia
(aOR = 1.93, 95% aCI = 1.17–3.19) had a higher likelihood of frailty.

Table 3. Association between frailty status and study sample characteristics (n = 584).

Frailty Status Bivariate Analysis Multivariate Analysis

Participants’ Characteristics Frail Non-Frail
OR 95% CI p aOR 95% aCI aP
n (%) n (%)
Sex
Male 27 (15.4) 148 (84.6) 0.71 (0.44–1.14) 0.66 (0.40–1.10)
0.151 0.110
Female 84 (20.5) 325 (79.5) Ref Ref
Age
60–69 years old 50 (15.6) 271 (84.4) Ref Ref
70–79 years old 40 (20.0) 160 (80.0) 1.36 (0.86–2.15) 0.195 1.09 (0.67–1.77) 0.730
80 years or older 21 (33.3) 42 (66.7) 2.71 (1.48–4.96) 0.001 2.04 (1.07–3.91) 0.032
Living situation
Alone 40 (26.7) 110 (73.3) 1.86 (1.19–2.89) 1.64 (1.04–2.61) 0.035
0.006
With relatives 71 (16.4) 363 (83.6) Ref Ref
BMI levels
Underweight (<18.5 kg/m2 ) 16 (32.7) 33 (67.3) 2.24 (1.13–4.440) 0.020 2.21 (1.06–4.6) 0.034
Normal weight (18.5–22.9 kg/m2 ) 43 (17.8) 199 (82.2) Ref Ref
Overweight (23–24.9 kg/m2 ) 22 (18.8) 95 (81.2) 1.07 (0.61–1.89) 0.811 1.22 (0.67–2.22) 0.516
Obese (≥25 kg/m2 ) 30 (17.1) 146 (82.9) 0.95 (0.57–1.59) 0.848 1.18 (0.67–2.09) 0.565
Current smoking
Yes 6 (11.3) 47 (88.7) 0.52 (0.22–1.24)
0.141
No 105 (19.8) 426 (80.2) Ref
Sarcopenia
Non-sarcopenia 36 (13.3) 235 (86.7) Ref Ref
Sarcopenia 71 (25.) 213 (75) 2.18 (1.40–3.38) 0.001 1.93 (1.17–3.19) 0.010
Severe sarcopenia 4 (13.8) 25 (86.2) 1.04 (0.34–3.18) 0.939 1.10 (0.34–3.56) 0.876
Charlson Comorbidity Index
0 point 30 (17) 147 (83) Ref
1–2 points 44 (15.8) 235 (84.2) 0.92 (0.55–1.52) 0.043 0.87 (0.51–147) 0.598
≥3 points 37 (28.9) 91 (71.1) 1.99 (1.15–3.45) 0.014 1.73 (0.95–3.16) 0.074
Polypharmacy (≥5 drugs)
Yes 20 (27) 54 (73.0) 1.71 (0.97–2.99)
0.062
No 91 (17.8) 419 (82.2) Ref

4. Discussion
Older adults are often at increased risk of adverse health events such as falls, disability,
hospital admissions, emergency department visits, and even death. The proportion of
older adults hospitalized with a frailty diagnosis is often remarkably high. Accurately
identifying patients who may experience adverse consequences is essential for individual
care planning and risk assessment for medical treatments or interventions. However, there
have not been many studies on this issue in Vietnam. Our study provides more data on the
prevalence of frailty in Ho Chi Minh City, Vietnam, a city of the most significant economic
Geriatrics 2022, 7, 85 6 of 9

center with a high population aging rate. A study of 584 research subjects showed that
deficiency is typical among older people. Finally, this suggests potential implications for
the development of interventions by which to improve the health of the older adult. In this
study, nearly one-fifth of the participants suffered from frailty (19%). Among the diagnostic
criteria for deficiency according to the Fried scale, the most common frailty component
was weak grip strength (63.9%), followed by slowness (36.1), weight loss (21.6%), low
physical activity (19.5%), and exhaustion (18.5%). The rate of frailty was lower than in
a previous study in the older adult community (21.7%) [15] and in a hospital setting in
Vietnam (35.4%) [23]. A possible explanation is that the hospitalized older adult may
experience serious health problems, increasing the risk of frailty [24]. The prevalence that
we found is comparable to that of the general majority of the older adults in the community
(5.4–44%) in other developing countries but is much lower than the number of hospitalized
patients (27.8–71.3%) [23]. The results indicate a higher prevalence than in those of other
studies in rural communities using similar instruments, such as Colombia (12.2%) [25],
Mexico (8.6%), and Turkey (7.4%) [26,27]. This discrepancy may be due to differences in the
criteria or items used to assess the degree of frailty. Previous studies have suggested that the
frailty rates in each community may vary depending on definition, population, and study
design [25,28]. As the older adults in the community have a remarkably high prevalence
of frailty, they should be regularly screened for health problems. This can effectively
prevent adverse outcomes listed as cardiovascular diseases, depression, fractures, falls,
hospitalization, or even death [4,13,29,30].
In line with previous studies, we found that people of an older age are more likely
to be frail [15,31]. Moreover, the study also showed a statistically significant association
between BMI levels, living situation, and sarcopenia. Participants who were underweight,
living alone, and had sarcopenia had a higher likelihood of frailty.
The relationship between frailty and body mass index remains controversial in stud-
ies. Some studies have shown an association between underweight and frail patients,
whereas others have highlighted a proportional association between obesity and frailty [32].
Changes in body weight are often seen in older people. Body weight tends to increase
throughout one’s life expectancy up to 70–80 years, after which body weight gradually
decreases. Moreover, malnutrition, being underweight, and obesity are adverse health risk
factors in older people. Advanced age has also been linked to changes in body composition,
including loss of muscle mass and increased fat mass [33]. In addition, the volume of
subcutaneous fat is reduced, while the penetration of lipid into the liver and the organs
often increases with age. The increase in overall fat mass and the loss of muscle mass do
not depend on weight changes [34].
The situation in which older adults live alone is a social issue of recent concern.
In developed countries, approximately one-third of the older adults live alone, which
increases with age. In addition, this rate is forecasted to continue to increase over the
next 20 years due to the increased life expectancy and improved health status of older
adults. Living alone can result in depression and social isolation, which may influence
older adults’ functional status [35]. The trend of older adults living alone is increasing in
Vietnam. According to the 2019 Midterm Census, older adults living alone or living only
with a spouse have increased, while other groups have tended to decline in this respect [36].
Differences between regions in terms of the living arrangements of the older adult are
partly due to the impact of migration. There is little scientific evidence of a relationship
between frailty and living alone, two common risk factors for adverse events in older adults
living in the community. Our research has found an association between these two factors.
This finding could provide additional data on the impact of social factors on the health of
older adults in Vietnam [37].
The relationship between frailty and sarcopenia has not been fully explored, but
both syndromes share many similarities, such as clinical outcomes, pathophysiology, and
risk factors [38]. Therefore, many believe sarcopenia to be a component of frailty, but
frailty is not a component of sarcopenia [39]. However, there is a significant overlap
Geriatrics 2022, 7, 85 7 of 9

between the diagnostic criteria used for frailty and sarcopenia. Some studies have classified
severe sarcopenia, as defined by the AWGS, as a pre-frail group according to the Fried
standards [40]. Sarcopenia is often seen as a predetermined syndrome or a physical criterion
for diagnosing frailty.
Our study, in which frailty was assessed using Fried’s criteria, considers a reference
standard in frailty diagnosis and contributes to scientific knowledge of the prevalence of
frailty and associated factors in the older adult community in Vietnam by the Fried frailty
scale. However, this study has several limitations, as follows. Firstly, the cross-sectional
nature of this study does not allow conclusions about the predictability of health outcomes
of frailty. Second, it was conducted in Vietnam’s urban older adult population, which may
not reflect the characteristics of Vietnam’s older adult population. Thirdly, some factors
that might be related to frailty were not examined in this study, such as mobility and daily
living. Still, the result can be a reference for other community-based studies in Vietnam
and provides evidence for screening frailty in the older adult population.

5. Conclusions
The community’s prevalence of frailty among older adults is high. Frailty can lead
to many adverse consequences for the elderly. As there were some modifiable factors
associated with frailty, it should be assessed in older people through community-based
healthcare programs for early diagnosis and management.

Author Contributions: All authors (T.Q.H.H., T.L.A.P., V.T.V., H.N.T.T. and T.V.N.) contributed to the
study concept and study design. T.Q.H.H. led ethics application, recruitment, and data acquisition.
T.L.A.P. led the statistical analysis. Drafting of the manuscript was performed by V.T.V., H.N.T.T. and
T.V.N. All authors were involved in analysis and interpretation of data and revised the manuscript
critically for important intellectual content. All authors have read and agreed to the published version
of the manuscript.
Funding: This research was funded by University of Medicine and Pharmacy at Ho Chi Minh City,
Vietnam.
Institutional Review Board Statement: This study protocol was reviewed and approved by the
Biomedical Research Ethics Committee at the University of Medicine and Pharmacy at Ho Chi Minh
City, Vietnam (approval number: 801/HDDD-DHYD).
Informed Consent Statement: Written informed consent was obtained from all participants.
Data Availability Statement: The study data is available from the corresponding author upon
reasonable request.
Conflicts of Interest: The authors declare no conflict of interest, financial or otherwise.

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