INTRODUCTION
Since the middle of the last century, significant changes have been taking place in
the demographic and health patterns of the world’s population, leading to significant
growth in the elderly population, many of whom have some chronic diseases. It is estimated
that, in 2025, Brazil will have the sixth largest elderly population in the world,
around 32 million people1,2,3,4.
The negative impact of chronic venous ulcers on quality of life is particularly reported
concerning pain, physical function, and mobility domains5,6,7,8. Depression and social isolation are also reported as manifestations resulting from
the presence of venous ulcers7,8,9,10,11.
Most older people with venous ulcers feel frustrated, impotent, lose faith in the
treatment and feel vulnerable, unable to carry out daily activities8,12,13,14,15, culminating in growing dependence, whose evolution can change and even be prevented
or reduced if there is adequate environment and assistance11,16. Dependence can also be considered as a state in which people find themselves lacking
or losing autonomy (physical, psychological, social) and needing help to carry out
basic activities. It is a serious health problem that interferes with the quality
of life of the elderly and their caregivers14,17.
When evaluating the functional capacity of older people with venous ulcers, it is
observed that patients have a reduced capacity for self-care and meeting basic needs6,9,12. Functional capacity or limitation can be defined as the individual’s ability to
maintain physical and mental capacities in basic and instrumental activities15,16.
The frailty in the elderly with venous ulcers becomes chronic, resulting in a feeling
of impotence, low self-esteem, and self-image16,17,18,19.
Most studies about the frailty syndrome and elderly individuals with chronic diseases
are justified because this condition makes this population more prone to progressive
reduction in functional capacity, repeated hospitalizations, and greater demand for
health services at different levels17,18,20,21,22,23,24.
In this sense, the frailty syndrome acquires importance as a target for investigations
and interventions because of the impact on elderly individuals, especially those with
venous ulcers, their families, and society as a whole. No national or international
literature studies evaluated the frailty syndrome and its consequences (decreased
functional capacity in activities of daily living and instrumental activities of daily
living, feelings of impotence and its consequences) in elderly patients with venous
ulcers and who also consider pre-frail individuals.
OBJECTIVE
Assess the level of frailty, feelings of powerlessness, and functional capacity in
older people with venous ulcers.
METHOD
Analytical, cross-sectional, descriptive, controlled study, approved by the Institutional
Ethics Committee, on opinion: 2,939,899, whose data were collected at the Federal
University of São Paulo from March 2017 to August 2018.
Two groups of participants over 60 were established: with venous ulcer and without
ulcer, each group with 56 patients.
The inclusion criteria for both groups were: 60 years or older and being literate,
adding an ankle/arm index between 1.0 and 1.4 for the group with venous ulcers. The
non-inclusion criteria for both groups were: mixed or arterial ulcer, sequelae of
stroke, or lower limb amputation.
Data were collected through interviews using self-administered and public domain questionnaires,
including a form for collecting demographic data, the Edmonton Frail Scale (EFS) instrument18, the Health Assessment Questionnaire-20 (HAQ-20)21, and the Instrument for Measuring Feelings of Powerlessness (IMSI)15.
The EFS was chosen to assess whether individuals in both groups were frail or pre-frail.
This instrument assesses the level of frailty in nine domains represented by 11 items,
including cognition, general health status and health description, functional independence,
social support, medication use, nutrition, mood, continence, and functional performance.
The scoring ranges for frailty level analysis are 0-4, no frailty; 5-6, apparently
vulnerable; 7-8, mild frailty; 9-10, moderate frailty; 11 or more, severe frailty,
with a maximum score of 1718.
The HAQ-20 consists of 20 questions divided into eight categories representing functional
activities – getting dressed, getting up, eating, walking, hygiene, reaching, gripping,
and other activities. The patient’s responses are measured on a scale ranging from
zero (no difficulty) to three (unable to do). The final score is calculated by the
sum of the components divided by 8 and can be classified as HAQ-20 from 0 to 1, mild
deficiency; HAQ-20 >1 to 2, moderate deficiency; and HAQ-20 >2 to 3, severe deficiency21.
The IMSI consists of 12 Likert-type questions with a five-point frequency ranging
from “never” to “always.” In this scale, the following scores are assigned to items
that mean the presence of a feeling of powerlessness: 1 = never; 2 = rarely; 3 = sometimes,
4 = often, and 5 = always, totaling a maximum of 60 points. The 12 questions are divided
into three domains: the ability to perform a behavior (Cronbach’s alpha = 0.845),
the perceived ability to make decisions (Cronbach’s alpha = 0.834), and the emotional
response to controlling situations (Cronbach’s alpha = 0.578). The scores are added
by domain and total score; the higher the score, the more intense the feeling of powerlessness15.
Data were entered and analyzed using the SPSS-8.0 statistical program (SPSS Inc.,
Chicago, IL, USA). Pearson’s chi-square test was used to assess the homogeneity of
responses, comparing the two study groups, with a significance level equal to 0.05
(p<0.05). Comparison between groups was performed using the Mann-Whitney test. Spearman’s
correlation test was applied to assess the correlation of continuous variables with
semicontinuous variables.
RESULTS
The sample consisted of 112 patients with the following sociodemographic characteristics:
68 (60.7%) were female, 56 (50.0%) had venous ulcers, 64 (57.1%) were 70 years old
or older, 43 (38.4%) could read, and write; 88 (78.6%) were retired; 45 (40.2%) were
married, 40 (35.7%) lived with family members, 100 (89.3%) used medication, 60 (53.6%)
had an adequate body mass index (BMI), 76 (67.9%) did not practice physical activity,
and 84 (75.0%) suffered a fall in the 30 days prior to the interview.
According to the mean overall EFS score by group (Table 1), patients with venous ulcers were considered vulnerable (mean EFS = 6.46) in contrast
to patients without ulcers who were identified as not vulnerable (mean EFS = 3.38),
with a statistically significant difference between groups (p=0.001).
Table 1 - Comparison of Edmonton Frail Scale scores between groups.
Group |
EFS - Overall Score |
p-Value |
n |
Mean |
Median |
SD |
With ulcer |
56 |
6.46 |
6.0 |
3,086 |
|
No ulcer |
56 |
3.38 |
3.0 |
2,253 |
0.001* |
Total |
112 |
4.92 |
5.0 |
3.105 |
|
Table 1 - Comparison of Edmonton Frail Scale scores between groups.
Regarding the EFS score by category, patients in the ulcer group were concentrated
in the “apparently vulnerable” and “mildly frail” categories, while the group without
ulcers was concentrated in the “non-frail” category. Table 2 indicates that 76.8% (n=43) of patients with venous ulcers were classified as vulnerable
and fragile, compared to 28.6% (n=16) of patients in the group without ulcers, with
a statistically significant difference between groups (p=0.001).
Table 2 - Distribution of the level of frailty in the study groups according to Edmonton Frail
Scale.
Level of Fragility |
Group |
p-Value |
With ulcer |
Without ulcer |
Total |
n |
% |
n |
% |
n |
% |
Does not present Fragility |
13 |
23.2 |
40 |
71.4 |
53 |
47.3 |
|
Apparently Vulnerable |
16 |
28.6 |
11 |
19.6 |
27 |
24.1 |
0.001* |
Mild frailty |
12 |
21.4 |
4 |
7.1 |
16 |
14.3 |
|
Moderate frailty |
11 |
19.6 |
0 |
0.0 |
11 |
9.8 |
|
Severe frailty |
4 |
7.1 |
1 |
1.8 |
5 |
4.5 |
|
Total |
56 |
100 |
56 |
100 |
112 |
100 |
|
Table 2 - Distribution of the level of frailty in the study groups according to Edmonton Frail
Scale.
Table 3 shows that patients with venous ulcers had greater difficulty performing activities
of daily living (mean overall HAQ-20 = 1.08) compared to patients without ulcers (mean
overall HAQ-20 = 0.37), with a difference statistically significant between groups
(p=0.002).
Table 3 - Comparison of mean scores in Health Assessment Questionnaire-20 categories between
groups.
Categories |
Group |
p-Value |
With ulcer |
Without ulcer |
Total |
No |
Mean |
SD |
n |
Mean |
SD |
n |
Mean |
SD |
Dress up/ Take care of himself |
56 |
0.86 |
0.841 |
56 |
0.20 |
0.401 |
112 |
0.53 |
0.735 |
0.001* |
Wake up |
56 |
1.07 |
0.912 |
56 |
0.39 |
0.593 |
112 |
0.73 |
0.838 |
0.002* |
Eat |
56 |
0.52 |
0.687 |
56 |
0.13 |
0.384 |
112 |
0.32 |
0.586 |
0.002* |
To walk |
56 |
1.59 |
0.890 |
56 |
0.57 |
0.759 |
112 |
1.08 |
0.969 |
0.001* |
Hygiene |
56 |
1.00 |
0.653 |
56 |
0.29 |
0.594 |
112 |
0.64 |
0.815 |
0.001* |
Catch up |
56 |
1.13 |
0.974 |
56 |
0.61 |
0.679 |
112 |
0.87 |
0.875 |
0.001* |
Hold |
56 |
1.18 |
1.081 |
56 |
0.36 |
0.616 |
112 |
0.77 |
0.968 |
0.001* |
Others Activities |
56 |
1.32 |
0.917 |
56 |
0.43 |
0.599 |
112 |
0.87 |
0.892 |
0.001* |
General |
56 |
1.08 |
0.729 |
56 |
0.37 |
0.407 |
112 |
0.73 |
0.686 |
0.002* |
Table 3 - Comparison of mean scores in Health Assessment Questionnaire-20 categories between
groups.
Patients with venous ulcers had a stronger feeling of powerlessness than those without
it. It is observed in Table 4 that the average score for the IMSI was 41.2 for the group with venous ulcer and
33.4 for the group without ulcer, with a statistically significant difference between
groups (p=0.001).
Table 4 - Comparison of the mean score in the Feelings of Powerlessness Measurement Instrument
domains between groups.
Domains |
Group |
p-Value |
With ulcer |
Without ulcer |
Total |
n |
Mean |
SD |
n |
Mean |
SD |
n |
Mean |
SD |
Ability to perform Behavior |
56 |
15.59 |
2,130 |
56 |
9.04 |
3.063 |
112 |
12.31 |
4.211 |
0.001* |
Ability to take instructions |
56 |
11.96 |
2,607 |
56 |
13.95 |
3,272 |
112 |
12.96 |
3.109 |
0.001* |
Emotional response to control situations |
56 |
13.54 |
2,565 |
56 |
10.57 |
3.173 |
112 |
12.05 |
3.235 |
0.001* |
General |
56 |
41.21 |
4,853 |
56 |
33.41 |
7.081 |
112 |
37.31 |
7.202 |
0.001* |
Table 4 - Comparison of the mean score in the Feelings of Powerlessness Measurement Instrument
domains between groups.
DISCUSSION
When the older person acquires a wound, he may find it difficult to carry out various
activities in his daily life. Often, these changes in activities of daily living can
cause emotional, psychological, and biological suffering in individuals, leading to
changes in style and quality of life and sleep, making it impossible for them to carry
out their social activities, perform self-care, and participate in leisure and family
life, in addition to causing absenteeism at work and even loss of work functions in
the productive age group. These factors can make the elderly feel fragile22,23,24,25,26.
In this study, most older people without ulcers were not frail, while most older people
with venous ulcers were vulnerable.
Being frail was related to higher incidences of hospitalization during follow-up.
Results were shared with other scientific evidence, especially when there was a prevalence
ranging from 50% to 80% of frail among hospitalized elderly25,26,27,28,29.
In a study in which the authors verified the levels of frailty and functional independence
in instrumental activities of daily living among the elderly identified as frail,
it was found: 29.8% with minimal dependence/ supervision and 81.9% with partial dependence
for instrumental activities of daily living30. The authors showed greater dependence on activities in frail older people, with
females having a higher prevalence of frailty30.
In this research, the means of the total score of elderly patients with venous ulcers
in the HAQ-20 and IMSI instruments were high, indicating that these individuals have
difficulties performing some daily living activities.
Deficits in functional, cognitive, and psychic capacity are the main causes of loss
of independence13,15, leading the elderly to need greater care to carry out activities of daily living.
This issue has become a challenge to be faced by elderly patients with venous ulcers
since the population’s life expectancy has increased, leading to a consequent growth
in the number of older people with chronic disease and functional disabilities.
Bearing in mind that the functional capacity of human beings declines with age, it
is necessary to plan strategies that improve the lifestyle of these individuals with
or without wounds, especially concerning programs that promote and improve muscle
and joint strength, with social integration inside and outside the family context.
These actions would make it possible to minimize the dependence of these individuals
on family, social, leisure, and daily activities28,29.
This research reinforces the need to direct the health care of elderly patients with
venous ulcers, seeking to identify, in the daily routine of health services, whether
in hospitals, outpatient clinics, the Family Health Program, and others, the presence
of reduced functional capacity and increase in fragility and a feeling of powerlessness
among patients who live with the wound in their daily lives, the main care needs of
this population and the caregiver’s knowledge to deal with the assisted person’s disabilities.
Furthermore, given the needs that have arisen in recent decades with the increase
in chronic diseases and patients with wounds, it is imperative that the academic training
and qualification of health professionals value the content and care practice.
CONCLUSION
Venous ulcers negatively impact functional capacity and increase frailty and feelings
of powerlessness in the elderly.
1. Universidade Federal de São Paulo, Programa de Pós-graduação em Cirurgia Translacional,
São Paulo, SP, Brazil
Corresponding author: Eliana Gonçalves Aguiar Disciplina de Cirurgia Plástica. Rua Botucatu 740, 2o andar, Vila Clementino, São
Paulo, SP, Brazil. Zip code: 04023-062 E-mail: eaguiar@unifesp.br