Update on Frailty Original Article| Volume 19, ISSUE 4, P287-295.e4, April 2018

The Prevalence and Correlates of Frailty in Urban and Rural Populations in Latin America, China, and India: A 10/66 Population-Based Survey

Published:January 03, 2018DOI:



      There have been few cross-national studies of the prevalence of the frailty phenotype conducted among low or middle income countries. We aimed to study the variation in prevalence and correlates of frailty in rural and urban sites in Latin America, India, and China.


      Cross-sectional population-based catchment area surveys conducted in 8 urban and 4 rural catchment areas in 8 countries; Cuba, Dominican Republic, Puerto Rico, Venezuela, Peru, Mexico, China, and India. We assessed weight loss, exhaustion, slow walking speed, and low energy consumption, but not hand grip strength. Therefore, frailty phenotype was defined on 2 or more of 4 of the usual 5 criteria.


      We surveyed 17,031 adults aged 65 years and over. Overall frailty prevalence was 15.2% (95% confidence inteval 14.6%–15.7%). Prevalence was low in rural (5.4%) and urban China (9.1%) and varied between 12.6% and 21.5% in other sites. A similar pattern of variation was apparent after direct standardization for age and sex. Cross-site variation in prevalence of frailty indicators varied across the 4 indicators. Controlling for age, sex, and education, frailty was positively associated with older age, female sex, lower socioeconomic status, physical impairments, stroke, depression, dementia, disability and dependence, and high healthcare costs.


      There was substantial variation in the prevalence of frailty and its indicators across sites in Latin America, India, and China. Culture and other contextual factors may impact significantly on the assessment of frailty using questionnaire and physical performance-based measures, and achieving cross-cultural measurement invariance remains a challenge.


      A consistent pattern of correlates was identified, suggesting that in all sites, the frailty screen could identify older adults with multiple physical, mental, and cognitive morbidities, disability and needs for care, compounded by socioeconomic disadvantage and catastrophic healthcare spending.


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        • Collard R.M.
        • Boter H.
        • Schoevers R.A.
        • Oude Voshaar R.C.
        Prevalence of frailty in community-dwelling older persons: A systematic review.
        J Am Geriatr Soc. 2012; 60: 1487-1492
        • Fried L.P.
        • Tangen C.M.
        • Walston J.
        • et al.
        Frailty in older adults: Evidence for a phenotype.
        J Gerontol A Biol Sci Med Sci. 2001; 56: M146-M156
        • Santos-Eggimann B.
        • Cuenoud P.
        • Spagnoli J.
        • Junod J.
        Prevalence of frailty in middle-aged and older community-dwelling Europeans living in 10 countries.
        J Gerontol A Biol Sci Med Sci. 2009; 64: 675-681
        • Da Mata F.A.
        • Pereira P.P.
        • Andrade K.R.
        • et al.
        Prevalence of frailty in Latin America and the Caribbean: A systematic review and meta-analysis.
        PLoS ONE. 2016; 11: e0160019
        • Alvarado B.E.
        • Zunzunegui M.V.
        • Beland F.
        • Bamvita J.M.
        Life course social and health conditions linked to frailty in Latin American older men and women.
        J Gerontol A Biol Sci Med Sci. 2008; 63: 1399-1406
        • Aguilar-Navarro S.
        • Gutierrez-Robledo L.M.
        • Garcia-Lara J.M.
        • et al.
        The phenotype of frailty predicts disability and mortality among Mexican community-dwelling elderly.
        J Frailty Aging. 2012; 1: 111-117
        • Rosero-Bixby L.
        • Dow W.H.
        Surprising SES Gradients in mortality, health, and biomarkers in a Latin American population of adults.
        J Gerontol B Psychol Sci Soc Sci. 2009; 64: 105-117
        • Curcio C.L.
        • Henao G.M.
        • Gomez F.
        Frailty among rural elderly adults.
        BMC Geriatr. 2014; 14: 2
        • Espinoza S.E.
        • Hazuda H.P.
        Frailty in older Mexican-American and European-American adults: Is there an ethnic disparity?.
        J Am Geriatr Soc. 2008; 56: 1744-1749
        • Wu C.
        • Smit E.
        • Xue Q.L.
        • Odden M.C.
        Prevalence and correlates of frailty among community-dwelling Chinese older adults: The China Health and Retirement Longitudinal Study.
        J Gerontol A Biol Sci Med Sci. 2017; 73: 102-108
        • Garcia-Garcia F.J.
        • Gutierrez A.G.
        • Alfaro-Acha A.
        • et al.
        The prevalence of frailty syndrome in an older population from Spain. The Toledo Study for Healthy Aging.
        J Nutr Health Aging. 2011; 15: 852-856
        • Cesari M.
        • Prince M.
        • Thiyagarajan J.A.
        • et al.
        Frailty: An emerging public health priority.
        J Am Med Dir Assoc. 2016; 17: 188-192
        • Theou O.
        • Cann L.
        • Blodgett J.
        • et al.
        Modifications to the frailty phenotype criteria: Systematic review of the current literature and investigation of 262 frailty phenotypes in the Survey of Health, Ageing, and Retirement in Europe.
        Ageing Res Rev. 2015; 21: 78-94
        • Jotheeswaran A.T.
        • Bryce R.
        • Prina M.
        • et al.
        Frailty and the prediction of dependence and mortality in low- and middle-income countries: A 10/66 population-based cohort study.
        BMC Med. 2015; 13: 138
        • Prince M.
        • Ferri C.P.
        • Acosta D.
        • et al.
        The protocols for the 10/66 Dementia Research Group population-based research programme.
        BMC Public Health. 2007; 7: 165
        • Prina A.M.
        • Acosta D.
        • Acostas I.
        • et al.
        Cohort Profile: The 10/66 study.
        Int J Epidemiol. 2016; 46 (406–406i)
        • Copeland J.R.M.
        • Dewey M.E.
        • Griffith-Jones H.M.
        A computerised psychiatric diagnostic system and case nomenclature for elderly subjects: GMS and AGECAT.
        Psychol Med. 1986; 16: 89-99
      1. Liu Z. Economic Cost of Dementia In Low and Middle Income Countries (PhD thesis) King's College London; 2012.

      2. Curtis L. Unit Costs of Health and Social Care. University of Kent, Canterbury, Personal Social Services Research Unit, 2010.

        • Sousa R.M.
        • Ferri C.P.
        • Acosta D.
        • et al.
        Contribution of chronic diseases to disability in elderly people in countries with low and middle incomes: A 10/66 Dementia Research Group population-based survey.
        Lancet. 2009; 374: 1821-1830
        • Sousa R.M.
        • Ferri C.P.
        • Acosta D.
        • et al.
        The contribution of chronic diseases to the prevalence of dependence among older people in Latin America, China, and India: A 10/66 Dementia Research Group population-based survey.
        BMC Geriatr. 2010; 1: 53
        • Prince M.
        • Acosta D.
        • Chiu H.
        • et al.
        Dementia diagnosis in developing countries: A cross-cultural validation study.
        Lancet. 2003; 361: 909-917
        • Ferri C.P.
        • Schoenborn C.
        • Kalra L.
        • et al.
        Prevalence of stroke and related burden among older people living in Latin America, India and China.
        J Neurol Neurosurg Psychiatry. 2011;
        • World Health Organization
        Measuring Health and Disability. Manual for WHO Disability Assessment Schedule (WHODAS 2.0).
        WHO Press, Geneva2010
        • Sousa R.M.
        • Dewey M.E.
        • Acosta D.
        • et al.
        Measuring disability across cultures—The psychometric properties of the WHODAS II in older people from seven low- and middle-income countries. The 10/66 Dementia Research Group population-based survey.
        Int J Methods Psychiatr Res. 2010; 19: 1-17
        • Higgins J.P.
        • Thompson S.G.
        Quantifying heterogeneity in a meta-analysis.
        Stat Med. 2002; 21: 1539-1558
        • Levine R.V.
        • Norenzayan A.
        The pace of life in 31 countries.
        J Cross-Cultural Psychol. 1999; 30: 178-205
        • Vaughan L.
        • Corbin A.L.
        • Goveas J.S.
        Depression and frailty in later life: A systematic review.
        Clin Interv Aging. 2015; 10: 1947-1958
        • Soysal P.
        • Veronese N.
        • Thompson T.
        • et al.
        Relationship between depression and frailty in older adults: A systematic review and meta-analysis.
        Ageing Res Rev. 2017; 36: 78-87
        • Jotheeswaran A.J.
        • Dias A.
        • Philp I.
        • et al.
        Identifying common impairments in frail and dependent older people: Validation of the COPE assessment for nonspecialised health workers in low resource primary health care settings.
        BMC Geriatr. 2015; 15: 123
        • Albanese E.
        • Liu Z.
        • Acosta D.
        • et al.
        Equity in the delivery of community healthcare to older people: Findings from 10/66 Dementia Research Group cross-sectional surveys in Latin America, China, India and Nigeria.
        BMC Health Serv Res. 2011; 11: 153