Understanding frailty among older people living in old age homes and the community in Nepal: A cross-sectional study

Richa Shah; Rogie Royce Carandang; Akira Shibanuma; Ken Ing Cherng Ong; Junko Kiriya; Masamine Jimba

doi:10.1371/journal.pone.0251016

. 2021 Apr 29;16(4):e0251016. doi: 10.1371/journal.pone.0251016

Understanding frailty among older people living in old age homes and the community in Nepal: A cross-sectional study

Richa Shah ^1,^2,^*, Rogie Royce Carandang ², Akira Shibanuma ², Ken Ing Cherng Ong ², Junko Kiriya ², Masamine Jimba ²

Editor: Toshiyuki Ojima³

PMCID: PMC8084172 PMID: 33914828

Abstract

Introduction

Frailty is a state of being vulnerable to adverse health outcomes such as falls, delirium, and disability in older people. Identifying frailty is important in a low-income setting to prevent it from progressing, reducing healthcare costs, increasing the chances of reversibility, and implementing effective interventions. The factors affecting frailty in older people living in old age homes could differ from those living in the community. This study was conducted to identify the factors associated with frailty in older people residing in old age homes and communities in Kathmandu Valley, Nepal.

Methods

This is a cross-sectional study conducted from April to June 2019 in three districts of Kathmandu Valley, Nepal. Data were collected from 193 older people residing in old age homes and 501 residing in communities aged 60 and above using convenience sampling. Frailty was measured using the Groningen Frailty Indicator. Data were collected via face-to-face interviews. Multiple linear regression analyses were used to examine the association between independent variables and frailty.

Results

Frailty was more prevalent among older people in old age homes (71.5%) compared to those in the community (56.3%). Older people who were satisfied with their living environment had lower frailty scores in both old age homes (β = -0.20, p<0.01) and the community (β = -0.15, p<0.001). Those who had self-rated unhealthy lifestyle had higher frailty scores in both old age homes (β = 0.45, p<0.001) and the community (β = 0.25, p<0.001). In the community, those over 80 years of age had higher frailty scores (β = 0.15, p<0.01) and those with higher education had lower scores (β = -0.13, p<0.05).

Conclusion

The living environment and lifestyle are key modifiable risk factors of frailty, both in old age homes and the community. The findings suggest a need for lifestyle modification and reforms in building standards, especially in old age homes, to promote age-friendly communities.

Introduction

The aging population has been increasing worldwide as a result of declining fertility, improved health, and decreased mortality [1]. The number of people aged 60 and above is expected to increase from 962 million in 2017 to 2.1 billion in 2050, globally [2]. The transition to an aging society is faster in low- and middle-countries (LMICs) compared to that in high-income countries [3]. This increase is so rapid and sudden that most countries are not prepared to deal with the associated challenges of aging, such as frailty [3].

Frailty is defined as a state of being vulnerable to adverse health outcomes such as falls, delirium, and disability [4, 5]. It is a multidimensional concept [6] encompassing physical, social, cognitive, and psychological aspects [7]. Old age leads to a decline in physiological and functional reserve capacity of multiple systems and frailty occurs when this reserve capacity is critically low [4, 8]. Although frailty is common in old age, it is not a manifestation of old age [4, 9] and is reversible with appropriate interventions [8]. The factors associated with frailty are age, income, multimorbidity, female gender, alcohol consumption, and smoking [9, 10]. Progression of frailty can be dealt with resistance exercises, addition of nutritional supplements in the diet, and cognitive training [11–14]. Frailty is used as a predictor for older people’s mortality and disability [15] and may discover unrecognized health problems [16, 17].

Frailty is likely to increase globally, including in LMICs such as Nepal, which poses a public health challenge. The prevalence of frailty is higher in upper-middle-income countries compared to high-income countries. Since most studies on frailty were conducted in high- and upper-middle-income countries, the evidence from low- and low-middle income countries remains scarce [18–21]. Due to a lack of evidence, health and social care planning in these countries are difficult [22]. In Nepal, for instance, little is known about the burden of frailty and the factors leading to frailty in older people.

The number of older people in Nepal is rising rapidly as elsewhere in the world [23, 24]. The Government of Nepal defined people who completed 60 years of age as senior citizens [25]. However, this manuscript uses the term older people instead of senior citizens as the term older people is less discriminatory and biased and hence, more appropriate to denote people aged 60 and over [26]. According to the latest census in 2011, the population of individuals aged 60 years old and above was 2.1 million in Nepal, which was 8.1% of the total population [27]. The average life expectancy in Nepal was 70.2 years in 2018 compared to 27.0 years in 1951 and 64.0 years in 2008, which is a drastic improvement [28].

Although most Nepali older people live at home, the number of older people living in old age homes is increasing because of a lack of support from their children [24, 29]. The major causes are urbanization, preference for nuclear families, and migration of adults in their prime age to urban areas and abroad for better opportunities [29]. These changes have made older people to live alone, care for their own needs, and look for an alternative living arrangement such as old age homes. Although the concept of old age home is not well-established in Nepal, it generally refers to shelter or multi-residence housing facility for older people who are helpless or do not have children to take care of them [23, 30]. These facilities provide residence, meals, gatherings, recreation activities, and some form of health care [30]. The rising number of old age homes and their residents calls attention to their better health, especially issues involving frailty, along with older people residing in the community.

Identifying frailty is important in a low-income setting with limited healthcare resources because it identifies people who need additional medical care. Early identification of frailty is essential to prevent it from progressing, sourcing healthcare to those in need, reducing healthcare costs, increasing the chances of reversibility, implementing effective interventions, and preventing adverse health outcomes such as disability [31, 32]. The factors affecting frailty in older people living in old age homes could be different from those living in the community. However, most studies have focused on frailty status in either the old age homes or the community [5, 19, 20]. This study was conducted to identify the factors that affect frailty status in community-dwelling older people and those living in old age homes in Kathmandu Valley, Nepal.

Materials and methods

Study design and settings

This was a cross-sectional study conducted in old age homes and communities of Kathmandu valley in Nepal. Kathmandu valley is comprised of three districts, namely Kathmandu, Lalitpur, and Bhaktapur. Kathmandu, the capital city of Nepal, and adjacent districts, which are Lalitpur and Bhaktapur are densely populated. These districts have a higher number of old age homes compared to the rest of the country. The number of old age homes amounted to 82 all over Nepal in 2012 and about 1500 older people resided there [33]. An updated and official list of old age homes in Nepal is unavailable. However, based on the principal investigator’s (RS) search, 21 old age homes were in Kathmandu Valley, which provided residence to about 350 older people.

Sample size and sampling procedure

The sample size was calculated based on a previous study by Lin et al., which divided the population into two groups, frail and robust with means of 52.6 (SD [Standard deviation] 8.8) for frail and 56.2 (SD 12.8) for non-frail [34]. OpenEpi version 3.01 was used for calculation with 80% power, 5% significance level, and 95% confidence interval. Thus, the minimum sample size obtained was 115 for old age homes and 348 for the community. However, anticipating a 30% refusal rate and incomplete responses, the final minimum sample size was set to 164 for old age homes and 497 for the community.

Convenience sampling was used to select the older people in the community as data on the number of older people aged only over 70 was available. The heads of 20 wards offices from Kathmandu, six from Lalitpur, and five from Bhaktapur districts were approached with a request letter for permission to conduct the study from The University of Tokyo. These wards were selected purposively based on the ease of access. A ward is the smallest local unit or political division used for electoral purposes [35]. In Kathmandu district, verbal permission was obtained from six wards, in Lalitpur district from three wards, and three wards in Bhaktapur district. Local leaders from the selected wards assisted in approaching older people. Older people were recruited through home visits based on the inclusion and exclusion criteria.

An official list of old age homes in Nepal was not available. A non-governmental organization called Ageing Nepal, which works for the welfare of the older people in Nepal, provided its own list of old age homes in Nepal. The heads of 15 old age homes were approached first via telephone calls followed by face-to-face meetings with a request letter for permission from The University of Tokyo. Among them, ten provided verbal permission, after which interviews were conducted.

Participants

The older people included in this study were aged 60 years and over and residing in the community and old age homes in Kathmandu Valley at the time of data collection [23, 30]. At old age homes, medical records were available. Based on the records, older people were excluded from this study if they suffered from moderate to severe cognitive impairment, severe hearing impairment, muteness, and mental illnesses such as psychosis, bipolar disorder, and schizophrenia. Most community-dwelling older people also had their medical records which the interviewers could access. In the absence of medical records or inadequate information in them, the older people were excluded from the study if they had visible signs of cognitive impairment such as inability to remember their name or the location of their residence, which affected the ability to comprehend the study procedure and to cooperate with the investigators. Sensory and cognitive decline may occur in old age, resulting in loss of memory, impaired comprehension and judgment, or inability to respond accurately. They could incapacitate older people from consenting to participate in the study or providing precise information. Only one older person was recruited from each household based on inclusion and exclusion criteria in the community. If a couple resided together in an old age home, only one of them was recruited. Based on the above, 35 older people were excluded from this study.

Variables and assessment

The framework for this study was adapted from a study in the Netherlands conducted by Gobbens et al. (Fig 1) [6]. It outlines the factors leading to frailty and the stage at which health promotion and prevention activities can be undertaken to delay frailty.

Frailty

The outcome variable was frailty. Groningen Frailty Indicator (GFI) was used to assess frailty, which is a validated instrument and tested in multiple settings [7, 8, 36]. It has 15 items that assess four domains: physical (nine items), cognitive (one item), social (three items), and psychological (two items) [7]. The responses were obtained in three categories (yes, no, and sometimes) and dichotomized as 0 and 1 based on the guidelines of GFI [7]. The responses were dichotomized as “yes” (0) and “no” (1) for grocery shopping, walk outside house, getting dressed, and visiting restroom. For rest of the questions, the responses were “yes” (1) and “no” (0). For the question on cognition, the response “sometimes” was coded as “0” whereas for other questions, “sometimes” was coded as “1”. The maximum possible score was 15 and the lowest possible score was 0 [7]. A score of 4 or higher is considered as “moderate” or “severe” frailty [7, 37]. The internal consistency of GFI in this study was measured using Cronbach’s alpha which was 0.74 for old age homes, 0.76 for the community, and 0.75 for combined, indicating high reliability [38].

Socio-demographic and health characteristics

The socio-demographic variables included age, gender, marital status, education level, income, and satisfaction with the home living environment. These variables were selected based on past research articles [6, 7]. Age was recorded in completed years. Health-related variables were the presence of comorbidities, smoking (currently smoking, never, and past smoker), alcohol consumption (currently consuming, never, and in the past), number of prescribed medicines taken in a day, and self-rated health (healthy, fair, and unhealthy). Marital status was classified into single (divorced, unmarried, widow, or widower) and married (married or cohabitation).

Data collection

An interviewer-administered questionnaire (tablet-based) was used for face-to-face interviews. The questionnaire was initially prepared in English and translated into the Nepali language by a bilingual medical doctor and public health professional. Two independent bilingual translators with a background in public health back-translated it into English. The translated version of the questionnaire was evaluated by two bilingual public health professionals working in the field of gerontology. Incomprehensible and ambiguous phrases were identified and substituted with more culturally and linguistically appropriate words and phrases. The Nepali questionnaire was refined after comparing both the initially prepared Nepali version and the back-translated English version. It was finalized after pre-testing it among 10 older people in old age homes and 20 older people in the community living in Kathmandu Valley. The old age homes and wards included in the pre-test were different from the ones in the main study but had similar backgrounds to those of the targeted groups. Data from the pre-test were not included in the final analysis.

Six local research assistants had a background in public health, and they were trained before data collection. They were familiarized with the study objectives, study protocol, research ethics, contents of the questionnaire, the process of data collection, and using tablets for the interview. The principal investigator (RS) and research assistants collected data from April to June 2019. Each survey interview lasted 20–30 minutes.

The number of older people approached for the interview was 950, 250 from old age homes and 700 from the community. Among them, 201 were interviewed in old age homes and 550 in the community. However, data from 57 older people were excluded due to incomplete responses. Finally, data from 694 older people were used for analysis.

Data analysis

Comparisons tests were performed between the two groups, old age homes and the community, using chi-squared tests for categorical variables. Multiple linear regression analyses were conducted to examine the association of various sociodemographic and health characteristics with frailty. Factors associated with frailty were observed by performing hierarchical linear regression using three models. Model 1 was adjusted for socio-demographic variables (age, gender, education, marital status, and income). Model 2 included health-related variables (comorbidities, medication use, smoking, and alcohol consumption). Model 3, which is the complete model, was adjusted for residence and satisfaction with home-living environment. Multicollinearity was assessed with variance inflation factor (VIF). Any variable with a VIF of 10 or more was excluded from the analyses. The data were analyzed using STATA/SE 15.1 software (StataCorp, College Station, TX, USA). The level of significance was set to 0.05 (two-tailed).

Ethical considerations

Ethical approval was obtained from the Research Ethics Committee of The University of Tokyo (2018168NI) and Nepal Health Research Council (160/2019). The older people were ensured of their confidentiality, voluntary participation, and their right to refuse participation at any time. Written informed consent was obtained in signature or thumb imprint from all the older people. Their identity was kept anonymous using identification codes and data is being managed with strict confidentiality. The findings of this study will be shared with concerned stakeholders to bring about positive changes and interventions in older people’s care.

Results

Table 1 summarizes the socio-demographic characteristics of the 694 older people. Among them, 193 resided in old age homes and 501 resided in the community. The mean age of older people in old age homes was 76.8 years (SD 9.9, range 60–104), and 78 (40.4%) were aged 80 and above. Among 193 older people, 131 (67.9%) were women. The number of illiterate older people was 143 (74.1%). Regarding the income level, 170 (88.1%) had an income below 20 USD. Only 30 (15.5%) were dissatisfied with their living environment.

Table 1. Sociodemographic characteristics.

Variables	Old age homes		Community		p-value
Variables	n = 193		n = 501
	n	%	n	%
Age [Mean (SD)]	76.8 (9.9)		72.6 (8.2)		<0.001
60–69 years	48	24.9	185	36.9
70–79 years	67	34.7	215	42.9
> = 80 years	78	40.4	101	20.2
Gender					<0.001
Male	62	32.1	245	48.9
Female	131	67.9	256	51.1
Education					<0.001
Illiterate	143	74.1	202	40.3
Non-formal education	23	11.9	138	27.5
< Higher secondary	18	9.3	96	19.2
> = Higher secondary	9	4.7	65	13.0
Marital Status					<0.001
Single	167	86.5	252	50.3
Married	26	13.5	249	49.7
Income (in USD)
< 20	170	88.1	269	53.7	<0.001
20 to 100	13	6.7	89	17.8
>100	10	5.2	143	28.5
Satisfaction with living environment					0.008
No	30	15.5	37	7.4
Yes	163	84.5	464	92.6

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USD: US dollars; SD: Standard Deviation.

Chi-square tests.

On the other hand, the mean age of older people in the community was 72.6 years (SD 8.2, range 60–100), and 101 (20.1%) were aged 80 and above. Among 501 older people in the community, 256 (51.1%) were women. The number of illiterate older people was 202 (40.3%). Regarding the income, 269 (53.7%) of them had an income below 20 USD. Only 37 (7.4%) were dissatisfied with their living environment. Statistically significant differences were observed in age (p<0.001), gender (p<0.001), education (p<0.001), marital status (p<0.001), income (p<0.001), and satisfaction with the living environment (p<0.01) between older people residing in old age homes and the community.

Table 2 summarizes the health characteristics of the older people. Frailty was more prevalent among older people in old age homes (71.5%) compared to those in the community (56.3%). The total prevalence was 60.5%. Only 21 older people (10.9%) did not suffer from any chronic disease in old age homes and 73 (14.6%) in the community. The number of older people who consumed three or more medicines to manage chronic diseases was 69 (35.8%) in old age homes and 147 (29.4%) in the community. The number of older people who perceived themselves to have a healthy lifestyle was 37 (19.2%) in old age homes compared to 146 (29.1%) in the community. Statistically significant differences were observed in number of comorbidities (p<0.01), self-rated lifestyle (p<0.01), and alcohol consumption (p<0.001) between older people residing in old age homes and the community.

Table 2. Health characteristics.

Variables	Old age homes		Community		p-value
	n = 193		n = 501
	n	%	n	%
Frailty score (GFI)					<0.001
Less than four	55	28.5	219	43.7
Four or more	138	71.5	282	56.3
Number of comorbidities					0.005
None	21	10.9	73	14.6
One or two	119	61.7	236	47.1
Three or more	53	27.4	192	38.3
Number of medicines					0.672
None	44	22.8	156	31.1
One or two	80	41.4	198	39.5
Three or more	69	35.8	147	29.4
Smoking					0.810
Currently smoking	35	18.1	60	12
Past smoker	47	24.4	152	30.3
Never	111	57.5	289	57.7
Alcohol consumption					<0.001
Yes	7	3.7	63	12.5
In the past	63	32.6	75	15
Never	123	63.7	363	72.5
Self-rated lifestyle					0.002
Healthy	37	19.2	146	29.1
Fair	94	48.7	246	49.1
Unhealthy	62	32.1	109	21.8

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Chi-square tests.

Table 3 illustrates multiple linear regression analyses of the factors associated with frailty. VIF values for all variables were below two, and no multicollinearity was observed. In old age homes, older people who were satisfied with their living environment had lower GFI scores (standardized beta coefficient [β] = -0.20; 95% confidence interval [CI]: -2.95, -0.45). Those who rated their health as fair (β = 0.20; 95% CI = 0.06, 2.42) and unhealthy (β = 0.45; 95% CI = 1.70, 4.38) had higher frailty scores. Similar results were observed in the case of community-dwelling older people where those who were satisfied with their living environment had lower GFI scores (β = -0.15; 95% CI = -2.62, -0.80) and those who rated their lifestyle as unhealthy had higher GFI scores (β = 0.25; 95% CI = 1.03, 2.53). In addition, older people aged 80 and above had higher GFI scores (β = 0.15; 95% CI = 0.36, 1.86) and those who had achieved education of higher secondary level and above had lower GFI scores (β = -0.13; 95% CI = -2.02, -0.22).

Table 3. Multiple linear regression: Factors associated with overall GFI in old age homes (n = 193) and the community (n = 501).

Variables	Old age homes	p-value	Community	p-value
Variables	β (95% CI)	p-value	β (95% CI)	p-value
Age (vs. 60–69 years)
70–79 years	-0.03 (-1.31,0.95)	0.754	0.00 (-0.59, 0.55)	0.946
> = 80 years	0.07 (-0.69, 1.54)	0.454	0.15 (0.36, 1.86)	0.004
Gender (vs. Female)
Male	-0.04 (-1.42, 0.86)	0.630	-0.05 (-0.91, 0.42)	0.318
Education (vs. Illiterate)
Non-formal education	-0.07 (-2.07, 0.74)	0.355	-0.07 (-1.11, 0.12)	0.116
< Less than higher secondary	0.02 (-1.29, 1.82)	0.736	-0.10 (-1.44, 0.05)	0.067
Higher secondary and above	0.04 (-1.78, 2.98)	0.621	-0.13 (-2.02, -0.22)	0.015
Marital status (vs. Single)
Married	0.09 (-0.41, 2.14)	0.184	-0.02 (-0.68, 0.42)	0.649
Income (in USD) (vs. < 20)
20 to 100	0.02 (-1.43, 2.00)	0.744	-0.01 (-0.79, 0.59)	0.771
More than 100	-0.05 (-2.90, 1.44)	0.509	-0.02 (-0.78, 0.55)	0.733
Number of comorbidities (vs. None)
1 or 2	-0.01 (-1.68, 1.54)	0.930	0.11 (-0.18, 1.52)	0.124
3 or more	0.10 (-1.02, 2.50)	0.407	0.12 (-0.24, 1.74)	0.139
Medication use (vs. None)
1 to 2	0.01 (-1.17, 1.30)	0.919	-0.05 (-0.97, 0.39)	0.404
3 or more	0.10 (-0.62, 1.95)	0.307	0.09 (-0.17, 1.39)	0.126
Smoking (vs. Never)
Currently smoking	0.10 (-0.50, 2.20)	0.219	-0.05 (-1.28, 0.30)	0.223
Past smoker	-0.03 (-1.45, 0.93)	0.669	0.00 (-0.60, 0.55)	0.929
Alcohol consumption (vs. Never)
In the past	0.00 (-1.06, 1.02)	0.967	-0.03 (-0.97, 0.46)	0.485
Yes	-0.02 (-2.73, 1.95)	0.741	-0.07 (-1.40, 0.14)	0.111
Self-rated lifestyle (vs. Healthy)
Fair	0.20 (0.06, 2.42)	0.040	0.08 (-0.10, 1.08)	0.101
Unhealthy	0.45 (1.70, 4.38)	<0.001	0.25 (1.03, 2.53)	<0.001
Satisfaction with living environment (vs. No)
Yes	-0.20 (-2.95, -0.45)	0.008	-0.15 (-2.62, -0.80)	<0.001

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β: Standardized beta coefficient.

CI: Confidence interval.

Table 4 shows the hierarchical regression analyses that were run to examine the degree to which the above factors were independently associated with frailty and to show the risk factors associated with it. In old age homes, older people aged 80 or over were more likely to have higher frailty scores in Model 1 (β = 0.18, p < 0.05) which became insignificant in Model 2. Model 3 showed that older people who were satisfied with their living environment (β = -0.20, p < 0.01) were more likely to have lower frailty scores, whereas those who rated their lifestyle as fair (β = 0.20, p < 0.05) and unhealthy (β = 0.45, p < 0.001) were more likely to have higher frailty scores. Model 3 explained a total of 18% of the variance of frailty in old age homes. Self-rated unhealthy lifestyle (β = 0.45, p < 0.001) had the strongest association with frailty.

Table 4. Hierarchical regression analyses: Factors associated with overall GFI in old age homes (n = 193) and the community (n = 501).

Variables	Old age homes			Community
Variables	Model 1	Model 2	Model 3	Model 1	Model 2	Model 3
Age (vs. 60–69 years)
70–79 years	0.06	0.03	-0.03	0.03	-0.01	0.00
> = 80 years	0.18^*	0.07	0.07	0.19^*	0.14^*	0.15^**
Gender (vs. Female)
Male	0.01	-0.02	-0.04	-0.12^*	-0.05	-0.05
Education (vs. Illiterate)
Non-formal education	-0.02	-0.07	-0.07	-0.06	-0.08	-0.07
< Higher secondary	0.04	0.03	0.02	-0.08	-0.10^*	-0.10
> = Higher secondary	0.00	0.04	0.04	-0.12^*	-0.12^*	-0.13^*
Marital status (vs. Single)
Married	0.10	0.08	0.09	-0.01	-0.03	-0.02
Income (in USD) (vs. Less than 20)
20 to 100	0.05	0.01	0.02	-0.06	-0.02	-0.01
> 100	-0.05	-0.04	-0.05	-0.05	-0.03	-0.02
Number of comorbidities (vs. None)
1 or 2		0.00	-0.01		0.10	0.11
3 or more		0.11	0.10		0.12	0.12
Medication use (vs. None)
1 to 2		0.00	0.01		-0.04	-0.05
3 or more		0.10	0.10		0.10	0.09
Smoking (vs. Never)
Currently smoking		0.15	0.10		-0.06	-0.05
Past smoker		-0.04	-0.03		0.01	0.00
Alcohol consumption (vs. Never)
In the past		-0.01	0.00		-0.02	-0.03
Yes		-0.03	-0.02		-0.06	-0.07
Self-rated lifestyle (vs. Healthy)
Fair		0.20^*	0.20^*		0.10	0.08
Unhealthy		0.52^***	0.45^***		0.27^***	0.25^***
Satisfaction with living environment (vs. No)
Yes			-0.20^**			-0.15^***
R² (%)	3.8	23.5	26.5	9.0	20.2	22.3
Δ R² (%)	-0.9	15.1^***	18.0^***	7.4^***	17.1^***	19.1^***

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Values are presented as standardized beta coefficients (β).

Statistical significance indicated by

*p < 0.05

**p < 0.01, and

***p < 0.001.

R²: variance; ΔR²: change in variance.

In the community, older people aged 80 or over were more likely to have higher frailty scores (β = 0.15, p < 0.01) and those with higher secondary education and above (β = -0.13, p < 0.05) were more likely to have the opposite in all the three models. Male older people were more likely to have lower frailty scores (β = -0.12, p < 0.05) than their female counterparts in Model 1, which became insignificant in the subsequent models. In Model 2, self-rated unhealthy lifestyle (β = 0.27, p < 0.001) increased the likelihood of higher frailty scores. Model 3 showed that older people who were satisfied with their living environment (β = -0.15, p < 0.001) were more likely to have lower frailty scores. Model 3 explained 19.1% of variance of frailty in the community. Self-rated unhealthy lifestyle (β = 0.25, p < 0.001) had the strongest association with frailty followed by satisfaction with the living environment (β = -0.15, p < 0.001).

Discussion

In this study, frailty score was higher in older people residing in old age homes. Dissatisfaction with the living environment and self-rated unhealthy lifestyle were associated with frailty both in old age homes and in the community. Higher age and higher education were associated with frailty only in the community and not in old age homes.

The percentage of frail older people in this study was higher in those residing in old age homes. This finding is in line with a study in the Netherlands, where older people residing in assisted-living facilities were frailer [6]. The prevalence of frailty among Gurkha welfare pensioners in Nepal was 46.2%, whereas frailty among rural population in eastern part of Nepal was 65% in other study conducted in Nepal [39, 40]. The difference in prevalence of frailty could be because of the use of different frailty instruments used in these studies. The higher frailty score in old age homes in this study could be because of higher rates of self-rated unhealthy lifestyle and dissatisfaction among their residents than community-dwelling older people which are discussed below. It could also be because of lack of family support as suggested by a study conducted in Nepal [40].

Older people who were satisfied with their living environment were less likely to be frail both in old age homes and in the community. This finding was previously found in European studies but is new for a low-income setting [41, 42]. Frailty state can deteriorate when older people lack resources to support aging in their living environment and cannot maintain independent living [43, 44]. A living environment that is not age-friendly could lead to limited physical activity and reduced opportunities, thus contributing to loneliness and isolation, leading to decline in cognitive functions [45]. Nepal lacks standards for operating old age homes, including age-friendly building standards and studies on this topic are scarce [30, 46]. Older people were dissatisfied with the lack of rampways and elevators, and traditional squat toilets, in a hospital-setting in Nepal [47]. Old age home residents complained of having to climb stairs, dirty restrooms, inaccessible bathrooms, lacking railing support, and inaccessible doorways for wheelchair users [23, 30]. They also complained of rude behavior from caretaking staff and inadequate staff in old age home [23]. Factors that can promote satisfaction with the living environment in France and the Netherlands were the availability of basic living facilities located on the floor of residence, enough opportunities for social contact, and feeling of safety at home and the neighborhood [48, 49].

In this study, older people who perceived themselves to have an unhealthy lifestyle were more likely to be frail in both settings. This finding is also new for a low-income country as previous studies analyzed lifestyle factors such as alcohol and smoking but not self-rated lifestyle [21, 41, 42]. Self-rated health was independently associated with frailty in a study conducted in Mexico [50]. Older people who perceive themselves to be unhealthy usually are not physically active, do not consume a healthy diet, and lead a sedentary lifestyle which may accelerate the development of frailty [44, 51]. This finding is consistent with previous studies in the Netherlands and Hong Kong, which show that lifestyle factors such as diet, physical activity, smoking, and alcohol consumption have a crucial effect on frailty [9, 10].

Frailty score increased with advancing age in community-dwelling older people. Age is a known risk factor of frailty. As people age, oxidative damage results in cell death, necrosis, and proliferation because of damage to DNA, which ultimately leads to loss of muscle mass called sarcopenia [52]. Sarcopenia is directly related to age and manifests as weak muscle strength, slowed gait, and poor balance [52]. Physiological and functional deficits increase with age which lead to frailty [4].

Frailty score was lower in educated community-dwelling older people, which is consistent with findings from studies conducted in Italy and the Netherlands [53, 54]. Education capacitates older people to identify their health problems and seek healthcare when needed through health-related knowledge and behavior [55]. It also improves their cognitive performance and decreases functional limitations [56]. Higher education enables older people to access health information, communicate better, and perform complex activities at home and in the community. Education may affect the prospects of finding a well-paying job past the retirement age and, in turn, prevent the decline of function through physical, cognitive, and psychological activation [57]. Health education and promotion activities in older people have shown to slow down frailty in Japan [58].

This study has some limitations. Due to the cross-sectional design, cause-effect interpretations between frailty and adverse life outcomes could not be established [6, 59]. Reverse causality is possible between satisfaction with the living environment, self-rated health, and frailty. A longitudinal design could have overcome these limitations. However, the objective of this study was to assess the association between exposure and outcome variables rather than to observe a cause-effect relationship. In addition, the findings may not be generalizable to the entire population of Nepal because the study was conducted in an urban setting. This study, however, recruited older people from various socioeconomic backgrounds to overcome this limitation. Despite these limitations, this is one of the few studies to measure the frailty status and explore the factors associated with it in both old age homes and the community in a low-income setting.

Conclusion

This study found dissatisfaction with the living environment and self-rated unhealthy lifestyle as the factors associated with frailty in both old age homes and the community. In addition, old age and lower education levels were also associated with frailty in community-dwelling older people. The results call for provisions to prevent frailty by focusing on the modifiable risk factors. Reforms in building standards are a dire need to promote an age-friendly community. The living spaces should be created with the needs of older people in consideration with facilities for physical activity and social connections, both at home and in the neighborhood. Similarly, improvement in lifestyle is possible through simple resistance exercises and addition of nutritional supplements in diet to increase the lean body mass, and improve strength and walking speed. Also, the management of frailty should include health education through disseminating information and increasing awareness on frailty.

Acknowledgments

We would like to express our gratitude to all the older people who participated in this study. We would also like to thank all organizations, especially Ageing Nepal, for their collaboration and efforts.

Data Availability

The data is available at https://doi.org/10.6084/m9.figshare.14158559.v1.

Funding Statement

The author(s) received no specific funding for this work.

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PLoS One. doi: 10.1371/journal.pone.0251016.r001

Decision Letter 0

Toshiyuki Ojima

22 Feb 2021

PONE-D-20-40524

Understanding frailty among older people living in old age homes and the community in Nepal: a cross-sectional study

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Reviewer #1: Page 7, line 117: I think it will be beneficial if authors provide explanation of how was moderate to severe cognitive impairment was assessed.

Page 9, line 178: Please mention how many old age homes were included in the study.

Page 10. Ethical considerations: As severe frailty indicates higher vulnerability to adverse health outcomes such as falls and disability in older people, what sort of interventions were provided to prevent such outcomes in this study? (As authors have mentioned that frailty can also be reversed with appropriate interventions). I think from an ethical standpoint, authors need to provide clarification on this aspect.

Tables 3 and 4: In the variable Gender, is the reference category male or female?

Discussion: Proportion of older people with severe frailty was higher in old age homes than community. Authors could discuss the current policy provisions for old age homes in Nepal if available, and suggestions to improve, some of which the authors have already touched upon in Page 17.

Reviewer #2: Congratulations authors for this study "…Fragility of among older people…" another dimensions of older people's study from Nepal. Your study is important. Here are my few questions/queries related to your study.

1. Introduction: Proportion of older people in Nepal in 2011 census is 8.1%, I suggest using the exact data. Please refer the article for detail statistics: Chalise HN. Provincial situation of elderly population in Nepal. Am J Aging Sci Res 2020; 1(1): 9-11.

Your citation 23 and references does not seems relevant, use the relevant citations as there are many studies related with issues of older people.

2. Methodology: Your methodological part needs further improvement. Please re-write this part including, how you determined the sample size, how did you measured the cognitive impairment and other also (inclusion and exclusion), how and where did you do the community sampling and at what basis? Please write it systematically, also read other articles published in PlosOne.

You have used Groningen Frailty Indicator (GFI) to assess the fraility of Nepalese older people. How did you assess the reliability and validity of this tool in the Nepalese culture?

3. "Table 1 summarizes the socio-demographic characteristics with of the 694 older people and 210 frailty scores.", I did not find the frailty score in table 1.

4. Discussion:

Please discuss your findings including other relevant studies from Nepal.

You did not discuss about the prevalence of frailty based on your research, why? It may help to know the situation of Nepal where it is.

Please also discuss about some research related with functional disability of Nepalese older people (Functional Disability on Instrumental/Activities of Daily Livings among Rural Older People in Nepal) somewhere in your article as this is one of the important variable for the frailty. Previous article from Nepal shows that functional disability is very high among Nepalese older people. High functional disability means high frailty.

Your study shows old age home residents have high frailty score, what may be the reason. Does it mean living in old age home results high frailty score.

All the best !

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

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Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Pranil Man Singh Pradhan, MD

Reviewer #2: No

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PLoS One. 2021 Apr 29;16(4):e0251016. doi: 10.1371/journal.pone.0251016.r002

Author response to Decision Letter 0

30 Mar 2021

Dear Editor and Reviewers,

Thank you very much for your kind and supportive comments. Please kindly find the following responses. All the responses described below are also seen in "Responses to Reviewers.docx" attached.

Editor’s comment:

1. Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Response to 1: Thank you very much for your kind and supportive comment.

2. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming.

Response to 2: We have updated the manuscript according to PLOS ONE’s style requirements.

3. Please explain sampling procedure in methods section.

Response to 3: We have explained the sampling procedure in the revised manuscript. We used convenience sampling to select the older people in this study. Please refer to page 6, lines 115-129.

“Convenience sampling was used to select the older people in the community as data on the number of older people aged only over 70 was available. The heads of 20 wards offices from Kathmandu, six from Lalitpur, and five from Bhaktapur districts were approached with a request letter for permission to conduct the study from The University of Tokyo. These wards were selected purposively based on the ease of access. A ward is the smallest local unit or political division used for electoral purposes [35]. In Kathmandu district, verbal permission was obtained from six wards, in Lalitpur district from three wards, and three wards in Bhaktapur district. Local leaders from the selected wards assisted in approaching older people. Older people were recruited through home visits based on the inclusion and exclusion criteria.

4. In your Data Availability statement, you have not specified where the minimal data set underlying the results described in your manuscript can be found. PLOS defines a study's minimal data set as the underlying data used to reach the conclusions drawn in the manuscript and any additional data required to replicate the reported study findings in their entirety. All PLOS journals require that the minimal data set be made fully available. For more information about our data policy, please see http://journals.plos.org/plosone/s/data-availability. Upon re-submitting your revised manuscript, please upload your study’s minimal underlying data set as either Supporting Information files or to a stable, public repository and include the relevant URLs, DOIs, or accession numbers within your revised cover letter. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories. Any potentially identifying patient information must be fully anonymized.

Response to 4: We have shared the data set on Figshare repository, which is available at “https://figshare.com/s/da4e349dc1f2597ed2cf”.

Reviewer #1

1. Page 7, line 117: I think it will be beneficial if authors provide explanation of how was moderate to severe cognitive impairment was assessed.

Response to 1: Based on the medical records of older people, we excluded those who had clinically diagnosed moderate to severe cognitive impairment. We also excluded older people who had obvious signs of cognitive impairment that affected their ability to answer correctly to the survey questions. These signs included inability to remember their name or location of their residence. Please refer to page 7, lines 131-140.

“At old age homes, medical records were available. Based on the records, older people were excluded from this study if they suffered from moderate to severe cognitive impairment, severe hearing impairment, muteness, and mental illnesses such as psychosis, bipolar disorder, and schizophrenia. Most community-dwelling older people also had their medical records which the interviewers could access. In the absence of medical records or inadequate information in them, the older people were excluded if they had visible signs of cognitive impairment such as inability to remember their name or the location of their residence, which affected their ability to comprehend the study procedure and to cooperate with the investigators.”

2. Page 9, line 178: Please mention how many old age homes were included in the study.

Response to 2: In this study, we included ten old age homes. We have revised the section on pages 6-7, lines 126-129 to clarify the number of old age homes included in this study.

“The heads of 15 old age homes were approached first via telephone calls followed by face-to-face meetings with a request letter for permission from The University of Tokyo. Among them, ten provided verbal permission after which interviews were conducted.”

3. Page 10. Ethical considerations: As severe frailty indicates higher vulnerability to adverse health outcomes such as falls and disability in older people, what sort of interventions were provided to prevent such outcomes in this study? (As authors have mentioned that frailty can also be reversed with appropriate interventions). I think from an ethical standpoint, authors need to provide clarification on this aspect.

Response to 3: The findings will be shared with Kathmandu Metropolitan Government office and Ageing Nepal, a leading organization working towards well-being of Nepaleseolder people, after the publication of this study. Please refer to page 11, lines 217-218.

“The findings of this study will be shared with concerned stakeholders to bring about positive changes and interventions in older people’s care.”

4. Tables 3 and 4: In the variable Gender, is the reference category male or female?

Response to 4: We have added the reference category (female) in tables 3 and 4 on pages 14 and 16, respectively.

5. Discussion: Proportion of older people with severe frailty was higher in old age homes than community. Authors could discuss the current policy provisions for old age homes in Nepal if available, and suggestions to improve, some of which the authors have already touched upon in Page 17.

Response to 5: We did not find any policy provisions for old age homes in Nepal. Most old age homes are running without a standard protocol. We have added a sentence in the discussion section highlighting this. Please refer to page 18, lines 300-301.

“Nepal lacks standards for operating old age homes, including building standards that are age-friendly and studies on this topic are scarce [30, 46].”

Reviewer #2:

1. Congratulations authors for this study "…Fragility of among older people…" another dimensions of older people's study from Nepal. Your study is important.

Response to 1: Thank you very much for your kind and supportive comments.

2. Introduction: Proportion of older people in Nepal in 2011 census is 8.1%, I suggest using the exact data. Please refer the article for detail statistics: Chalise HN. Provincial situation of elderly population in Nepal. Am J Aging Sci Res 2020; 1(1): 9-11.

Response to 2: We have revised the percentage of older people in Nepal to 8.1% in the introduction section. Please refer to page 4, lines 71-72.

“According to the latest census in 2011, the population of individuals aged 60 years old and above was 2.1 million in Nepal, which was 8.1% of the total population [27].”

3. Your citation 23 and references does not seems relevant, use the relevant citations as there are many studies related with issues of older people.

Response to 3: We have revised citation 23. We removed the citation “Shrestha DRS, A.; Ghimire, J. Emerging challenges in family planning programme in Nepal. J Nepal Health Res Counc. 2012;10(21):108-12.” and added two relevant citations on page 4, line 67.

“The number of older people in Nepal is rising rapidly as elsewhere in the world [23, 24].

23. Mishra S, Chalise HN. Health status of elderly living in government and private old age home in Nepal. Sciences. 2018;11(4):173-8.

24.Chalise HN. Demographic situation of population ageing in Nepal. Kathmandu Univ Med J (KUMJ). 2006;4(3):354-62.”

4. Methodology: Your methodological part needs further improvement. Please re-write this part including, how you determined the sample size, how did you measured the cognitive impairment and other also (inclusion and exclusion), how and where did you do the community sampling and at what basis? Please write it systematically, also read other articles published in PlosOne.

Response to 4: We revised the methods section based on PLOS ONE’s guidelines. We also included a section on sample size calculation and community sampling, and elaborated on the measurement of cognitive impairment.

Page 6, lines 108-114

Sample size: “The sample size was calculated based on a previous study by Lin et al. which divided the population into two groups, frail and robust with means of 52.6 (SD [Standard deviation] 8.8) for frail and 56.2 for non-frail (SD 12.8) [34]. OpenEpi version 3.01 was used for calculation with 80% power, 5% significance level, and 95% confidenceinterval. Thus, the minimum sample size obtained was 115 for old age homes and 348 for the community. However, anticipating about 30% refusal rate and incomplete responses, the final minimum sample size was set to 164 for old age homes and 497 for the community.”

Page 6, lines 115-129

Sampling: “Convenience sampling was used to select the older people in the community as data on the number of older people aged only over 70 was available. The heads of 20 wards offices from Kathmandu, six from Lalitpur, and five from Bhaktapur districts were approached with a request letter for permission to conduct the study from The University of Tokyo. These wards were selected purposively based on the ease of access. A ward is the smallest local unit or political division used for electoral purposes [35]. In Kathmandu district, verbal permission was obtained from six wards, in Lalitpur district from three wards, and three wards in Bhaktapur district. Local leaders from the selected wards assisted in approaching older people. Older people were recruited through home visits based on the inclusion and exclusion criteria.

Page 7, lines 131-146

Inclusion and exclusion criteria including cognitive impairment: “The older people included in this study were aged 60 years and over and residing in the community and old age homes in Kathmandu Valley at the time of data collection [23, 30]. At old age homes, medical records were available. Based on the records, older people were excluded from this study if they suffered from moderate to severe cognitive impairment, severe hearing impairment, muteness, and mental illnesses such as psychosis, bipolar disorder, and schizophrenia. Most community-dwelling older people also had their medical records which the interviewers could access. In the absence of medical records or inadequate information in them, the older people were excluded from the study if they had visible signs of cognitive impairment such as inability to remember their name or the location of their residence, which affected the ability to comprehend the study procedure and to cooperate with the investigators. Sensory and cognitive decline may occur in old age, resulting in loss of memory, impaired comprehension and judgment, or inability to respond accurately. They could incapacitate older people from consenting to participate in the study or providing precise information. Only one older person was recruited from each household based on inclusion and exclusion criteria in the community. If a couple resided together in an old age home, only one of them was recruited. Based on the above, 35 older people were excluded from this study.”

5. You have used Groningen Frailty Indicator (GFI) to assess the frailty of Nepalese older people. How did you assess the reliability and validity of this tool in the Nepalese culture?

Response to 5: The internal consistency reliability of GFI was measured using Cronbach’s alpha. The instrument was checked for face and content validity during translation and back-translation of the questionnaire as well as during pre-testing by bilingual medical doctors with a background in public health and a researcher in the field of gerontology.

Page 8, lines 163-165

“The internal consistency of GFI in this study was measured using Cronbach’s alpha which was 0.74 for old age homes, 0.76 for the community, and 0.75 for combined, indicating high reliability [38].”

Page 9. Lines 177-188 “The questionnaire was initially prepared in English and translated into the Nepali language by a bilingual medical doctor and public health professional. Two independent bilingual translators with a background in public health back-translated it into English. The translated version of the questionnaire was evaluated by two bilingual public health professionals working in the field of gerontology. Incomprehensible and ambiguous phrases were identified and substituted with more culturally and linguistically appropriate words and phrases. The Nepali questionnaire was refined after comparing both the initially prepared Nepali version and the back-translated English version. It was finalized after pre-testing it among 10 older people in old age homes and 20 older people in the community living in Kathmandu Valley. The old age homes and wards included in the pre-test were different from the ones in the main study but had similar backgrounds to those of the targeted groups. Data from pre-test were not included in the final analysis.”

6. "Table 1 summarizes the socio-demographic characteristics with of the 694 older people and 210 frailty scores.", I did not find the frailty score in table 1.

Response to 6: Thank you for bringing our attention to this error. We have corrected the sentence to “Table 1 summarizes the socio-demographic characteristics of the 694 older people” on page 11, line 220. Frailty scores are given in Table 2 on page 12.

7. Please discuss your findings including other relevant studies from Nepal. You did not discuss about the prevalence of frailty based on your research, why? It may help to know the situation of Nepal where it is. Your study shows old age home residents have high frailty score, what may be the reason. Does it mean living in old age home results high frailty score.

Response to 7: In our revised manuscript, we added a description of prevalence of frailty in this study and compared it with other studies conducted in Nepal in the discussion section. We also discussed about high frailty scores in old age homes which could be a result of higher rates of self-rated unhealthy lifestyle and dissatisfaction among their residents compared to community-dwelling older people. Please refer to page 17, lines 280-293.

“In this study, frailty score was higher in older people residing in old age homes. Dissatisfaction with the living environment and self-rated unhealthy lifestyle were associated with frailty both in old age homes and in the community. Higher age and higher education were associated with frailty only in the community and not in old age homes.

The percentage of frail older people in this study was higher in those residing in old age homes. This finding is in line with a study in the Netherlands, where older people residing in assisted-living facilities were frailer [6]. The prevalence of frailty among Gurkha welfare pensioners in Nepal was 46.2%, whereas frailty among rural population in eastern part of Nepal was 65% in other study conducted in Nepal [39, 40]. The difference in prevalence of frailty could be because of the use of different frailty instruments used in these studies. The higher frailty score in old age homes in this study could be because of higher rates of self-rated unhealthy lifestyle and dissatisfaction among their residents compared to community-dwelling older people which are discussed below. It could also be as a result of lack of family support as suggested by a study conducted in Nepal [40].”

8. Please also discuss about some research related with functional disability of Nepalese older people (Functional Disability on Instrumental/Activities of Daily Livings among Rural Older People in Nepal) somewhere in your article as this is one of the important variable for the frailty. Previous article from Nepal shows that functional disability is very high among Nepalese older people. High functional disability means high frailty.

Response to 8: We have mentioned in the introduction section that frailty can lead to adverse health outcomes such as disability. We did not explain it further as we did not assess the association between frailty and disability in this study.

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PLoS One. doi: 10.1371/journal.pone.0251016.r003

Decision Letter 1

Toshiyuki Ojima

19 Apr 2021

Understanding frailty among older people living in old age homes and the community in Nepal: A cross-sectional study

PONE-D-20-40524R1

Dear Dr. Shah,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Toshiyuki Ojima, M.D., Ph.D

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

Reviewer #1: Yes

Reviewer #2: No

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

Reviewer #1: Yes

Reviewer #2: Yes

**********

6. Review Comments to the Author

Reviewer #1: (No Response)

Reviewer #2: Thank you author for addressing the majority of my comments/suggestions and queries. Wish you all the best.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Pranil Man Singh Pradhan

Reviewer #2: Yes: Hom Nath Chalise, PhD

PLoS One. doi: 10.1371/journal.pone.0251016.r004

Acceptance letter

Toshiyuki Ojima

21 Apr 2021

PONE-D-20-40524R1

Understanding frailty among older people living in old age homes and the community in Nepal: A cross-sectional study

Dear Dr. Shah:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

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on behalf of

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

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Data Availability Statement

The data is available at https://doi.org/10.6084/m9.figshare.14158559.v1.

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PERMALINK

Understanding frailty among older people living in old age homes and the community in Nepal: A cross-sectional study

Richa Shah

Rogie Royce Carandang

Akira Shibanuma

Ken Ing Cherng Ong

Junko Kiriya

Masamine Jimba

Roles

Abstract

Introduction

Methods

Results

Conclusion

Introduction

Materials and methods

Study design and settings

Sample size and sampling procedure

Participants

Variables and assessment

Fig 1. Conceptual framework.

Frailty

Socio-demographic and health characteristics

Data collection

Data analysis

Ethical considerations

Results

Table 1. Sociodemographic characteristics.

Table 2. Health characteristics.

Table 3. Multiple linear regression: Factors associated with overall GFI in old age homes (n = 193) and the community (n = 501).

Table 4. Hierarchical regression analyses: Factors associated with overall GFI in old age homes (n = 193) and the community (n = 501).

Discussion

Conclusion

Acknowledgments

Data Availability

Funding Statement

References

Decision Letter 0

Toshiyuki Ojima

Roles

Author response to Decision Letter 0

Decision Letter 1

Toshiyuki Ojima

Roles

Acceptance letter

Toshiyuki Ojima

Roles

Associated Data

Supplementary Materials

Data Availability Statement

ACTIONS

PERMALINK

RESOURCES

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