Weakness: The most frequent criterion among pre-frail and frail older Portuguese

Con en s lis s a ailable a ScienceDi ec A chi es o Ge on ology and Ge ia ics jou nal homepage: www.else ie .com/loca e/a chge Weakness: The mos equen c i e ion among p e- ail and ail olde Po uguese A.R. Sousa-San os a,⁎ , C. A onso a , P. Mo ei a a,b,c , P. Pad ão a,b , A. San os a,d , N. Bo ges a,e , T.F. Ama al a, a Faculdade de Ciências da Nu ição e Alimen ação, Uni e sidade do Po o, Rua D . Robe o F ias, 4200-465 Po o, Po ugal b EPIUni - Ins i u o de Saúde Pública, Uni e sidade do Po o, Rua das Taipas, 135, 4050-600 Po o, Po ugal c CIAFEL - Cen o de In es igação em A i idade Física, Saúde e Laze , Uni e sidade do Po o, Rua D . Plácido Cos a, 91, 4200-450 Po o, Po ugal d I3S - Ins i u o de In es igação e Ino ação em Saúde, Uni e sidade do Po o, Rua Al edo Allen, 208, 4200-135 Po o, Po ugal e CINTESIS - Cen o de In es igação em Tecnologia e Se iços de Saúde, Rua D . Plácido da Cos a, s/n, 4200-450, Po o, Po ugal UISPA, LAETA-INEGI - Faculdade de Engenha ia, Uni e sidade do Po o, Rua D . Robe o F ias, 4200-465 Po o, Po ugal ARTICLE INFO Keywo ds: Exhaus ion F ail y Physical ac i i y Walking ime Weakness Weigh loss ABSTRACT Aim: In Po ugal, he bu den o p e- ail y and ail y in communi y-dwelling olde adul s is s ill unknown. The pu pose o his s udy is o es ima e he equency o ail y in a Po uguese sample wi h ≥65 yea s and o e alua e i s associa ed ac o s. We also in end o iden i y which c i e ion has mo e impac on he diagnosis o ail y. Me hods: 1457 olde adul s wi h ≥65 yea s om he Nu i ion UP 65 s udy we e e alua ed in a c oss-sec ional analysis. F ail y was iden ified acco ding o F ied e al. by he p esence o h ee o mo e o he ollowing ac o s: unin en ional weigh loss, sel - epo ed exhaus ion, slowness, weakness and low physical ac i i y. P e‐ ail y was defined as he p esence o one o wo o hese c i e ia. The associa ion be ween indi iduals’cha ac e is ics and ail y s a us was analysed h ough logis ic eg ession analysis. Resul s: The equency o p e- ail y and ail y is 54.3% and 21.5%, espec i ely. In olde adul s classified as p e- ail o ail, 76.7% p esen ed weakness and 48.6% exhaus ion. In mul i a ia e analyses, ail y was asso- cia ed wi h age > 75, lowe educa ion le el, being single, di o ced o widowe , being p o essionally inac i e, poo sel ‐pe cep ion o heal h s a us, no d inking alcohol, being obese and unde nou ished o a unde nu i ion isk. Conclusion: This condi ion is e y p e alen in Po uguese olde adul s, one fi h a e ail whe eas hal a e p e- ail. Weakness iden ified by low handg ip s eng h is he mos p e alen c i e ion in p e- ail and ail Po uguese olde adul s. 1. In oduc ion F ail y is a common clinical synd ome in olde adul s. I is cha - ac e ised by mul isys em dys egula ions, leading o a loss o dynamic homeos asis, dec eased physiologic ese e and inc eased ulne abili y o poo heal h ou comes, such as alls, inciden disabili y, hospi ali- za ion, and mo ali y (Chen, Mao, & Leng, 2014;Xue, 2011). Se e al me hodologies ha e been p oposed o iden i y ail y (F ied e al., 2001;Rockwood e al., 2005;Rome o-O uno, Walsh, Lawlo , & Kenny, 2010). F ied’s ail y scale has been he mos ex- ensi ely es ed o i s alidi y and is he mos widely used ins umen in ail y esea ch (Bouillon e al., 2013). F ied e al. sugges ed ha indi iduals should be classified as no mal, p e- ail o ail based on he ollowing ac o s: unin ended weigh loss, exhaus ion, weakness, slow walking speed and low physical ac i i y. F ail y was conside ed as he p esence o h ee o mo e o hese cha ac e is ics and p e- ail y when one o wo cha ac e is ics we e p esen (F ied e al., 2001). Olde adul s ca ego ised acco ding o his defini ion, showed diffe ences in he le el o social, psychological and physical unc ioning be ween he h ee s ages (Op he Veld e al., 2015). In a sys ema ic e iew whe e he p e alence o p e- ail y and ail y epo ed by s udies in he communi y in olde adul s wi h 65 yea s o olde was pooled, he a e age p e alence o p e- ail y was 41.6% and ail y o 10.7% (Colla d, Bo e , & Schoe e s, 2012). F ail y numbe s anged subs an ially om 4% o 59.1% be ween he analysed s udies. Ne e heless, when only s udies using F ied’sdefini ion we e analysed, h p://dx.doi.o g/10.1016/j.a chge .2017.10.018 Recei ed 11 Janua y 2017; Recei ed in e ised o m 25 Sep embe 2017; Accep ed 23 Oc obe 2017 ⁎ Co esponding au ho . E-mail add ess: [email p o ec ed] (A.R. Sousa-San os). A chi es o Ge on ology and Ge ia ics 74 (2018) 162–168 A ailable online 28 Oc obe 2017 0167-4943/ © 2017 The Au ho s. Published by Else ie I eland L d. This is an open access a icle unde he CC BY-NC-ND license (h p://c ea i ecommons.o g/licenses/BY-NC-ND/4.0/). T ail y p e alence anged om 4% o 17% (Colla d e al., 2012). To ou knowledge, only one s udy in Po ugal has epo ed he equency o p e- ail y (44%) and ail y (56%) among 50 in- s i u ionalized olde adul s using F ied’s c i e ia (Viei a e al., 2016). Thus, he bu den o his condi ion among Po uguese olde adul s li ing in he communi y is s ill unknown. This is o majo ele ance because he p opo ion o olde people in Po ugal is inc easing (Ins i u o Nacional de Es a ís ica, 2015) and, consequen ly, he numbe o in- di iduals a isk o ail y. Using da a om he Nu i ion UP 65 s udy, we aim o iden i y he equency o ail y in a sample o Po uguese wi h 65 yea s o olde , and o e alua e i s associa ed ac o s. We also in end o e alua e he con ibu ion o he diffe en c i e ia o he diagnosis o ail y. 2. Me hods This s udy used da a om he Nu i ion UP 65 s udy which is a c oss-sec ional obse a ional s udy conduc ed in Po ugal. De ails e- ga ding he ec ui men , selec ion and measu es we e ou lined else- whe e (Ama al e al., 2016). B iefly, Nu i ion UP 65 included a sample o 1500 Po uguese wi h ≥65 yea s old, ep esen a i e o he Po u- guese olde popula ion in e ms o age, sex, educa ion and egional a ea. Indi iduals p esen ing any condi ion ha p ecluded he collec ion o enous blood samples o u ine (eg, demen ia o u ina y incon- inence) we e excluded om he s udy. Fo he cu en analysis, 43 indi iduals we e excluded due o incomple e da a ega ding ail y assessmen . The e o e, a o al o 1457 olde adul s we e included. 2.1. Da a collec ion Da a we e collec ed be ween Decembe 2015 and June 2016 and in o ma ion on each subjec was ga he ed by means o an in e iew conduc ed by p e iously ained egis e ed nu i ionis s, also e- sponsible o an h opome ic and unc ional da a collec ion. Demog aphic da a, cohabi a ion, p o essional occupa ion, li es yle p ac ices, heal h s a us and clinical his o y, cogni i e pe o mance, and nu i ional s a us da a we e collec ed using a s uc u ed ques ionnai e. Li es yle p ac ices included cu en obacco use and numbe o alco- holic d inks daily. Ch onic diseases we e e alua ed by he p esence o as hma; ch onic b onchi is, ch onic obs uc i e pulmona y disease, o emphysema; myoca dial in a c ion o ch onic consequences o myo- ca dial in a c ion; co ona y hea disease o angina pec o is; hy- pe ension; s oke o ch onic consequences o a s oke; a h osis; lumba pain o o he ch onic lumba p oblems; neck pain o o he ch onic neck p oblems; diabe es; hepa ic ci hosis; alle gies; ch onic enal disease, including enal ailu e; u ina y incon inence o bladde con ol p oblems; dep ession; o he disease, diagnosed in he pas yea . The a iable was ca ego ised as: absence o ch onic diseases; p esence o 1 ch onic disease; o p esence o 2 o mo e ch onic diseases (Holze , Siebenhuene , Bopp, & Minde , 2014). 2.2. Cogni i e and nu i ional assessmen Cogni i e pe o mance was assessed by he Po uguese e sion o he Mini Men al S a e Examina ion. The cu -offsco es o cogni i e impai men a e as ollows: indi iduals wi h no educa ion, ≤15 poin s; 1 o 11 yea s o school comple ed, ≤22 poin s; and > 11 yea s o school comple ed, ≤27 poin s (Gue ei o, 2010). The Po uguese e - sion o he Mini-Nu i ional Assessmen ® - Sho Fo m (MNA-SF) was also applied. A pa icipan sco ing ≤7 ou o 14 poin s was classified as unde nou ished, one ha sco es be ween 8 and 11 is a isk o unde - nu i ion and one sco ing be ween 12 and 14 poin s was conside ed well-nou ished (Nes le Nu i ion Ins i u e, 2009). 2.3. An h opome ic measu emen s An h opome ic measu emen s we e collec ed ollowing s anda d p ocedu es (S ewa , Ma ell-Jones, Olds, & Ridde , 2011). In a and in e - a e obse e e o was calcula ed and anged om 0.05 o 0.34% and 0.19 o 1.48%, espec i ely. S anding heigh was ob ained wi h a calib a ed s adiome e (SECA 213, SECA GmbH, Hambu g, Ge many), wi h 0.1 cm esolu ion. Fo pa icipan s wi h isible kyphosis o when i was impossible o measu e s anding heigh due o pa icipan ’s pa alysis o due o mobili y o balance limi a ions, heigh was ob ained indi ec ly om non‐dominan hand leng h (Gue a, Fonseca, Pichel, Res i o, & Ama al, 2014), measu ed wi h a calib a ed paquime e (Fe i Equipmen , Vignola, I aly), wi h 0.1 cen ime e e- solu ion. Body weigh (in kilog ams) was measu ed wi h a calib a ed po able elec onic scale (SECA 803, SECA GmbH, Hambu g, Ge many) wi h 0.1 kg esolu ion, wi h he pa icipan s wea ing ligh clo hes. When i was no possible o weigh a pa ien , body weigh was es ima ed om mid-uppe a m and cal ci cum e ences (Chumlea, Guo, Roche, & S einbaugh, 1988). Mid uppe a m, wais and cal ci cum e - ences we e measu ed wi h a me al ape measu e (Lu kin W606 PM, Lu kin, Spa ks, Ma yland, USA), wi h 0.1 cm esolu ion. T iceps skin old hickness was ob ained using a Hol ain Tanne /Whi ehouse (Hol ain, L d., C osswell, Uni ed Kingdom) skin old callipe , wi h 0.2 mm esolu ion. 2.4. Muscle s eng h and unc ion Non-dominan hand g ip s eng h (HGS) was measu ed wi h a ca- lib a ed Jama Plus Digi al Hand Dynamome e (Sammons P es on Inc., Bolingb ook, Illinois, USA), wi h 0.1 Kg esolu ion. Indi iduals we e asked o si in a chai wi hou a m es , wi h hei shoulde s adduc ed, hei elbows flexed 90° and hei o ea ms in neu al posi ion, as e- commended by he Ame ican Socie y o Hand The apis s (Fess, 1992). Each pa icipan pe o med h ee measu emen s wi h a one minu e pause be ween hem and he highe alue, eco ded in kilog am- o ce (kg ), was used o he analysis. When he indi idual was unable o pe o m he measu emen wi h he non-dominan hand, he dominan hand was used. Walking ime was measu ed o e a dis ance o 4.6 m wi h a ch onome e (School elec onic s opwa ch, Di e049, Topgim, Po ugal) and walking ime in seconds was eco ded. Pa icipan s we e asked o walk a hei usual pace in an unobs uc ed co ido . Those unable o walk due o mobili y o balance limi a ions we e conside ed ail o his c i e ion (n = 28). 2.5. Sel - epo ed exhaus ion and physical ac i i y le els Sel - epo ed exhaus ion was measu ed using wo i ems om he Cen e o Epidemiologic S udies Dep ession Scale (CES-D) (Radloff, 1977). The ollowing wo s a emen s we e ead: “I el ha e e y hing I did was an effo ”and “In he las week I could no ge going.”The exhaus ion c i e ion was conside ed p esen i a pa icipan answe ed “a mode a e amoun o he ime”o “mos o he ime” o he ques ion: “How o en in he las week did you eel his way?”. Physical ac i i y was assessed by he sho o m o he In e na ional Physical Ac i i y Ques ionnai e (C aig e al., 2003). In o ma ion e- ga ding he p e ious se en days, namely on how many days and how much ime he pa icipan spen : walking o hiking (a home o a wo k, mo ing om place o place, o ec ea ion o spo ), si ing (a a desk, isi ing iends, eading, s udying o wa ching ele ision), mode a e ac i i ies (ca ying ligh objec s, hun ing, ca pen y, ga dening, cycling a a no mal pace o ennis in pai s) and igo ous ac i i ies, namely li ing hea y objec s, ag icul u e, digging, ae obics, swimming, playing oo ball and cycling a a as pace was ga he ed. A.R. Sousa-San os e al. A chi es o Ge on ology and Ge ia ics 74 (2018) 162–168 163 A weigh ed es ima e o o al physical ac i i y (MET-minu es pe week) om all epo ed ac i i ies pe week was ob ained h ough he sum o he du a ion o he ac i i y × equency pe week × MET in- ensi y o each ac i i y domain included in he ques ionnai e, which was hen con e ed o kilocalo ies expended pe week (C aig e al., 2003). 2.6. F ail y s a us F ail y, acco ding o F ied e al. ail y pheno ype, encompasses he assessmen o he fi e ollowing c i e ia: sh inking: e alua ed by sel - epo ed unin en ional weigh loss ( > 4.5 kg los unin en ionally in p io yea ); weakness: e alua ed as low HGS adjus ed o gende and BMI [Men: ≤29 kg (BMI ≤24 kg/m 2 ), ≤30 kg (BMI 24.1–26 kg/m 2 ), ≤30 kg (BMI 26.1–28 kg/m 2 ), ≤32 kg (BMI > 28 kg/m 2 )/Women: ≤17 kg (BMI ≤23 kg/m 2 ), ≤17.3 kg (BMI 23.1–26 kg/m 2 ), ≤18 kg (BMI 26.1–29 kg/m 2 ), ≤21 kg (BMI > 29 kg/m 2 )]; poo endu ance and ene gy: e alua ed as sel - epo ed exhaus ion; slowness: walking ime measu emen adjus ed o gende and s anding heigh ; and low physical ac i i y: kilocalo ies expended pe week, adjus ed o gende (men < 383 Kcals/week and women < 270 Kcals/week). I one o wo o hese c i e ia we e p esen , he indi idual was cha ac e ized as p e- ail. F ail y was defined as he p esence o h ee o mo e c i e ia (F ied e al., 2001). 2.7. E hics This esea ch was conduc ed acco ding o he guidelines es ablished by he Decla a ion o Helsinki, and he s udy p o ocol was app o ed by he E hics Commi ee o he depa men o “Ciências Sociais e Saúde” (Social Sciences and Heal h) om he “Faculdade de Medicina da Uni e sidade do Po o”(PCEDCSS –FMUP 15/2015) and by he Po uguese Na ional Commission o Da a P o ec ion (9427/2015). All s udy pa icipan s signed an in o med consen o m. 2.8. S a is ical analyses S a is ical analyses we e pe o med wi h IBM SPSS S a is ics 23 (SPSS, Inc, an IBM Company, Chicago, IL). Desc ip i e analyses we e conduc ed o show he cha ac e is ics o he s udy sample acco ding o ail y s a us. Kolmogo o -Smi no es was used o e alua e he no - mali y o he dis ibu ion o quan i a i e a iables and esul s we e p esen ed as median and in e qua ile ange (IQR) o non-no mal da a. Fo ca ego ical a iables, esul s we e exp essed as numbe o pa ici- pan s (pe cen age). Included and excluded indi iduals we e compa ed using Chi-squa e es o Fishe ’s exac es . P e alence o each in- di idual ail y c i e ia was also es ima ed acco ding wi h ail y s a us. A logis ic eg ession was ca ied ou and he c ude and adjus ed odds a ios (OR) and hei espec i e 95% confidence in e als (CI) we e calcula ed as measu es o associa ion in wo diffe en models, wi h p e- ail y and ail y as dependen a iables. Gende , age, in e - iewe , egional a ea, esiden ial s a us, ma i al s a us, p o essional s a us, smoking s a us, alcohol consump ion, sel -assessed heal h s a us, cogni i e unc ion, BMI classifica ion and unde nu i ion s a us we e a iables included in he models. Unanswe ed ques ions o missing alues o ma i al s a us (n = 1), p o essional s a us (n = 5), alcohol consump ion (n = 2), sel ‐assessed heal h s a us (n = 4) and BMI classifica ion (n = 3), we e included in he e e ence g oups. Rega ding BMI classifica ion, unde weigh indi iduals we e also included in he e e ence g oup due o i s small numbe (n = 3). Confidence in e als we e compu ed a 95% and s a is ical sig- nificance was defined by p<0.05. Table 1 Cha ac e is ics o s udy pa icipan s, acco ding o ail y s a us*. N (%) No mal P e- ail y F ail y 353 (24.2) 791 (54.3) 313 (21.5) Gende Women 164 (46.5) 462 (58.4) 216 (69.0) Men 189 (53.5) 329 (41.6) 97 (31.0) Age (yea s), median (IQR) 70.0 (6.0) 74.0 (10.0) 80.0 (10.0) Age 65–75 yea s 286 (81.0) 448 (56.6) 97 (31.0) > 75 yea s 67 (19.0) 343 (43.4) 216 (69.0) Regional A ea No h 121 (34.3) 238 (30.1) 98 (31.3) Cen e 92 (26.1) 202 (25.5) 90 (28.8) Lisbon 84 (23.8) 208 (26.3) 85 (27.2) Alen ejo 41 (11.6) 67 (8.5) 21 (6.7) Alga e 6 (1.7) 38 (4.8) 14 (4.5) Madei a 9 (2.5) 18 (2.3) 1 (0.3) Azo es 0 (0.0) 20 (2.5) 4 (1.3) Residence Home 348 (98.6) 757 (95.7) 280 (89.5) Ca e home 5 (1.4) 34 (4.3) 33 (10.5) Educa ion le el Wi hou educa ion 15 (4.2) 113 (14.3) 78 (24.9) 1–4 yea s 232 (65.7) 555 (70.2) 213 (68.1) 5–12 yea s 72 (20.4) 94 (11.9) 18 (5.8) Highe educa ion 34 (9.6) 29 (3.7) 4 (1.3) Ma i al s a us Single 23 (6.5) 57 (7.2) 30 (9.6) Ma ied o common-law ma iage 229 (64.8) 371 (46.9) 83 (26.5) Di o ced 25 (7.1) 62 (7.8) 27 (8.6) Widowe 76 (21.5) 300 (37.9) 173 (55.3) P o essional s a us Ac i e 15 (4.3) 13 (1.6) 2 (0.6) No ac i e 337 (95.7) 776 (98.4) 309 (99.4) Smoking s a us Non-smoke 334 (94.6) 757 (95.7) 300 (95.8) Smoke 19 (5.4) 34 (4.3) 13 (4.2) Alcohol consump ion None 92 (26.1) 410 (52.0) 209 (66.8) Mode a e (W: ≤1/day; M: ≤2/day) 211 (59.8) 300 (38.0) 86 (27.5) Excessi e (W: > 1/day; M: > 2/day) 50 (14.2) 79 (10.0) 18 (5.8) Cogni i e unc ion (MMSE) No mal 346 (98.0) 745 (94.2) 272 (86.9) Impai ed 7 (2.0) 46 (5.8) 41 (13.1) Sel -pe cep ion o heal h s a us Ve y good 34 (9.7) 24 (3.0) 9 (2.9) Good 141 (40.1) 219 (27.8) 36 (11.5) Fai 164 (46.6) 406 (51.5) 145 (46.5) Poo 12 (3.4) 121 (15.3) 92 (29.5) Ve y poo 1 (0.3) 19 (2.4) 30 (9.6) Sel - epo ed ch onic diseases (numbe ) None 11 (3.1) 20 (2.5) 1 (0.3) 1 38 (10.8) 65 (8.3) 17 (5.4) ≥2 303 (86.1) 700 (89.2) 294 (94.2) Unde nu i ion s a us (MNA-SF) No unde nou ished 334 (94.6) 683 (86.3) 210 (67.1) Unde nu i ion isk 19 (5.4) 103 (13.0) 90 (28.8) Unde nu i ion 0 (0.0) 5 (0.6) 13 (4.2) IQR –In e qua ile ange; W –Women; M –Men; MMSE –Mini men al s a e examina ion; MNA-SF –Mini nu i ional assessmen –Sho o m. *Column pe cen ages may no add o 100% due o ounding. In o ma ion was no ob- ained: Ma i al s a us n = 1 (0.1%); P o essional s a us n = 5 (0.3%); Alcohol con- sump ion n = 2 (0.1%); Sel -pe cep ion o heal h s a us n = 4 (0.2%); Sel - epo ed ch onic diseases n = 8 (0.5). A.R. Sousa-San os e al. A chi es o Ge on ology and Ge ia ics 74 (2018) 162–168 164 3. Resul s The 1457 pa icipan s e alua ed we e aged 65–100 yea s old, in which 57.0% we e be ween 65 and 75 yea s, and 57.8% we e women. Excluded indi iduals did no diffe om included indi iduals in all he s udied cha ac e is ics, excep o egional a ea (p= 0.005), BMI (p= 0.033) and alcohol consump ion (p= 0.012), whe e excluded indi iduals we e mo e likely o be unde weigh o ha e no mal weigh and no d inking alcohol (Supplemen a y Table 1). Howe e , e en wi hou s a is ically significan diffe ences, excluded indi iduals we e mo e equen ly women and also mo e equen ly classified as cogni- i ely impai ed, as unde nou ished o a unde nu i ion isk. The cha ac e is ics o he s udy sample by ail y s a us a e p e- sen ed in Table 1. F equency o p e‐ ail y and ail y acco ding o F ied’s c i e ia was 54.3% and 21.5%, espec i ely. Mo e han one hi d o olde adul s we e obese, acco ding wi h BMI (38.9%) and p e- ail and ail indi iduals we e mo e likely o be in his ca ego y. Almos 83% o he pa icipan s had low educa ion le el (≤4 yea s o schooling). In addi ion, he majo i y o he indi iduals epo ed ha ing ch onic diseases (97.3%), and 31.8% conside ed hei heal h s a us as good o e y good. Resul s ega ding an h opome ic, unc ional and physical ac i i y measu es a e p esen ed in Table 2. BMI dis ibu ion by ail y s a us a ied acco ding o gende . Highe BMI alues we e obse ed in ail women (p≤0.001). F ail men p esen ed and lowe cal and mid-a m muscle ci cum e ences alues (p≤0.001). Conce ning he unc ional measu es included in ail y c i e ia (HGS, walking ime and physical ac i i y), lowe alues we e obse ed ac oss ail y s ages o bo h men and women (Table 2), wi h men gene ally pe o ming be e han women o all es s (da a no shown). The esul s o logis ic eg ession a e displayed in Table 3. In his mul i a ia e analysis, ail y was associa ed wi h age > 75 (OR 7.33, CI 4.14–12.97), highe educa ion le el (OR 0.03, CI 0.01–0.15), being ma ied o in common-law ma iage (OR 0.51, CI 0.29–0.88), being p o essionally inac i e (OR 6.67, CI 1.13–39.32), poo o e y poo sel - pe cep ion o heal h s a us (OR 12.56, CI 5.18–30.47), mode a e al- cohol consump ion (OR 0.23, CI 0.13–0.42), obesi y (OR 5.24, CI 2.35–11.68) and being unde nou ished o a unde nu i ion isk (OR 16.30, CI 6.71–39.56). P e‐ ail y was also associa ed wi h mos o hese a iables, ma i al and p o essional s a us. Fig. 1 shows he dis ibu ion o he fi e c i e ia: weakness assessed by HGS, exhaus ion, walking ime, physical ac i i y and unin en ional weigh loss, acco ding o ail y s a us. Weakness was by a he mos p e alen c i e ion in he o al numbe o olde adul s wi h p e- ail y o ail y (76.7%), ollowed by exhaus ion (48.6%). Unin en ional weigh loss was only epo ed in 10.3% o he pa icipan s wi h hese condi- ions. 4. Discussion Acco ding wi h F ied’s ail y scale, p e- ail y and ail y a e e y equen in Po uguese olde adul s. Almos h ee qua e s o he in- di iduals p esen ed a leas one ail y c i e ion, and olde indi iduals we e mo e likely o be affec ed. Mo eo e , hese indi iduals showed mo e equen ly low HGS, o e o he c i e ia. Se e al ac o s, such as being p o essionally inac i e, ha ing poo o e y poo sel -assessed heal h s a us, obesi y and being unde nou ished o a unde nu i ion isk we e associa ed wi h wo se ail y s a us. The equency o p e- ail y (54.3%) and ail y 21.5%) was highe compa ed wi h he o iginal epo in he Ca dio ascula Heal h S udy (6.9%) (F ied e al., 2001). In Eu ope, he equency o ail y and o p e- ail y was e alua ed in en diffe en coun ies and i was ound ha sou he n Eu opean coun ies p esen ed a highe equency o ail y and p e- ail y, indica ing he possibili y o an exis ing no h-sou h g adien (San os-Eggimann, Cuénoud, Spagnoli, & Junod, 2009). Al hough Po - ugal was no included in his s udy, based in he cul u al simila i ies, a compa able equency o ail y and p e- ail y o ha obse ed in o he sou he n Eu opean coun ies was expec ed. When ou esul s we e compa ed wi h hose om hese coun ies, ail y equency (21.5%) was lowe han in Spain (27.3%) and in I aly (23%) bu highe han in G eece (14.7%) (San os-Eggimann e al., 2009). Howe e , p e- ail y equency was highe (54.3%) compa ed o he p e iously epo ed in Spain (50.3%), I aly (45.6%) and G eece (44.9%) (San os-Eggimann e al., 2009). Simila ly, esul s om FRADEA s udy (Spain) ha e shown a high equency o p e- ail y (48.5%) and ail y (21.3%), bu hey also included a la ge numbe o ins i u ionalized olde adul s (21.3% e sus 4.9% in ou sample) (Abizanda Sole e al., 2011), which has been associa ed wi h wo sen ail y s a us (Ga ido, Se ano, Ba olome, & Ma inez-Vizcaino, 2012;Gonzalez-Vaca e al., 2014). On he o he hand, da a om he InCHIANTI s udy, in I aly, epo ed much lowe alues 37.8% and 6.5% o p e- ail y and ail y, espec i ely (Ble e al., 2006). Analogous esul s we e obse ed in Toledo s udy o heal hy ageing (Ga cia-Ga cia, 2011) and FRALLE su ey (Ju schik e al., 2012), in Spain, in which ail y p e alence was 8.4% in he fi s , and 9.6% in he second. P e- ail y alues we e sligh ly highe o he wo la es s udies (41.8% and 47%) (Ga cia-Ga cia, 2011;Ju schik e al., 2012). E en hough F ied’s ail y defini ion was used in he a o emen- ioned s udies, a ia ions in he esul s may be he esul o he Table 2 An h opome ic, unc ional and physical ac i i y measu es † . No mal P e- ail y F ail y p- alue BMI (kg/m 2 ), median (IQR) Women 27.7 (5.0) 29.7 (6.7) 30.4 (7.2) < 0.001 a Men 27.9 (4.3) 28.5 (5.2) 28.4 (7.6) 0.387 a BMI classifica ion (WHO), n (%) Unde weigh /No mal weigh 73 (20.7) 114 (14.4) 53 (17.1) < 0.001 b O e weigh 187 (53.0) 355 (44.9) 105 (33.9) Obesi y 93 (26.3) 322 (40.7) 152 (49.0) MAMC (cm), median (IQR) Women 22.2 (3.2) 22.6 (4.0) 22.4 (3.9) 0.269 a Men 25.6 (3.5) 24.4 (4.0) 23.4 (3.0) < 0.001 a Wais ci cum e ence, n (%) Women: ≤80 cm; Men: ≤94 cm 63 (17.8) 88 (11.1) 29 (9.6) < 0.001 b Women: 81–88 cm; Men: 95–102 cm 105 (29.7) 157 (19.8) 42 (14.0) Women: > 88 cm; Men: > 102 cm 185 (52.4) 546 (69.0) 230 (76.4) Cal ci cum e ence (cm), median (IQR) Women 35.5 (4.1) 35.5 (4.2) 35.2 (5.1) 0.847 a Men 37.0 (4.0) 35.8 (4.5) 35.0 (4.4) < 0.001 a Maximal HGS (kg ), median (IQR) Women 23.0 (4.9) 17.4 (5.8) 14.5 (5.6) < 0.001 a Men 37.8 (8.9) 27.6 (8.7) 21.4 (8.4) < 0.001 a Walking ime (s), median (IQR) Women 4.2 (1.4) 5.5 (2.6) 8.9 (4.5) < 0.001 a Men 4.1 (1.4) 5.1 (2.3) 8.3 (5.8) < 0.001 a Physical ac i i y (MET·min·wk-1), median (IQR) Women 2826.0 (4432.0) 1636.5 (2444.0) 146.0 (600.0) < 0.001 a Men 2772.0 (3235.0) 1729.5 (4013.0) 219.0 (796.0) < 0.001 a BMI –Body mass index; IQR –In e qua ile ange; WHO –Wo ld Heal h O ganiza ion; MAMC –Mid-a m muscle ci cum e ence; HGS –Handg ip s eng h; MET –Me abolic equi alen . † Column pe cen ages may no add o 100% due o ounding. Missing cases: BMI n = 3 (0.2%), Wais ci cum e ence n = 12 (0.8%), Walking ime n = 46 (3.2%). a K uskal-Wallis es . b Qui-squa e es . A.R. Sousa-San os e al. A chi es o Ge on ology and Ge ia ics 74 (2018) 162–168 165 diffe ences wi hin he ail y c i e ia used. Namely in he SHARE s udy, which epo ed highe equencies when compa ed wi h o he s udies conduc ed in he same a eas. In hese, ope a ionaliza ion o he c i e ia was diffe en om he Ca dio ascula Heal h S udy, excep o weak- ness, which can explain he con adic o y esul s ac oss s udies. Ne e heless, he p esen s udy e eals much highe equencies o p e- ail y and ail y e en when compa ed wi h esul s om s udies wi h ewe diffe ences in he used c i e ia (Ble e al., 2006;F ied e al., 2001;Ga cia-Ga cia, 2011). Due o he highe equency o his synd ome among Po uguese olde adul s, he p e alence o each ail y c i e ion is expec ed o be much highe , han he p e iously ound in o he s udies. In he p esen s udy, a highe p e alence o weakness among p e- ail and ail olde adul s was obse ed and exhaus ion was he second mos p e alen c i e ion. In con as , o he s udies epo ed la ge p e alence o ex- haus ion o e weakness wi h simila pa e ns in he h ee less p e alen c i e ia p esen ed (D ey, P ei e , Siebe , & Baue , 2011;San os- Eggimann e al., 2009). In he Ca dio ascula Heal h S udy, low ac i i y was he mos p e alen c i e ion, ollowed by slowness and weakness in second. Weigh loss was he less equen c i e ion, as obse ed in he p esen s udy (F ied e al., 2001). Ne e heless, in he InCHIANTI s udy, diffe en pa e ns we e obse ed in he fi s h ee mo e p e alen c i e ia, slowness was he fi s , weakness he second, and exhaus ion he hi d (Ble e al., 2006). Resul s conce ning he onse o ail y showed ha weakness was he mos common fi s mani es a ion, de- spi e he significan he e ogenei y in he ini ial mani es a ions o ail y, wi h ea ly de elopmen o weigh loss o exhaus ion p edic ing mo e apid onse o he ail y synd ome (Xue, Bandeen-Roche, Va adhan, Zhou, & F ied, 2008). While he c oss-sec ional na u e o p esen s udy does no allow us o es ablish empo al in e ences, weakness was s ill he mos p e alen c i e ion in he p e‐ ail pa icipan s. This s udy ex ends he findings o o he s, showing ha ail y Table 3 Resul s om he bi a ia e and mul i a ia e logis ic eg ession analyses, ega ding p e- ail y and ail y s a us. P e- ail y F ail y Unadjus ed Adjus ed Unadjus ed Adjus ed OR (CI 95%) p- alue OR (CI 95%) p- alue OR (CI 95%) p- alue OR (CI 95%) p- alue Gende Women 1 1 1 1 Men 0.62 (0.48-0.80) < 0.001 0.93 (0.68–1.28) 0.657 0.39 (0.28–0.54) < 0.001 0.64 (0.36–1.13) 0.124 Age 65–75 yea s 1 1 1 1 > 75 yea s 3.27 (2.42–4.42) < 0.001 2.66 (1.87–3.77) < 0.001 9.51 (6.65–13.60) < 0.001 7.33 (4.14–12.97) < 0.001 Residence Home 1 1 1 1 Ca e home 3.13 (1.21–8.06) 0.018 1.95 (0.67–5.72) 0.222 8.20 (3.16–21.29) < 0.001 3.52 (0.91–13.58) 0.068 Educa ion le el Wi hou educa ion 1 1 1 1 1–4 yea s 0.32 (0.18–0.56) < 0.001 0.58 (0.32–1.07) 0.080 0.18 (0.10–0.32) < 0.001 0.31 (0.13–0.73) 0.008 5–7 yea s 0.17 (0.09–0.32) < 0.001 0.33 (0.17–0.66) 0.002 0.05 (0.02–0.10) < 0.001 0.09 (0.03–0.29) < 0.001 Highe educa ion 0.11 (0.05–0.24) < 0.001 0.20 (0.09–0.46) < 0.001 0.02 (0.01–0.07) < 0.001 0.03 (0.01–0.15) < 0.001 Ma i al s a us Single, di o ced o widowe 1 1 1 1 Ma ied o common-law ma iage 0.48 (0.37–0.62) < 0.001 0.83 (0.60–1.14) 0.239 0.20 (0.14–0.27) < 0.001 0.51 (0.29–0.88) 0.016 P o essional s a us Ac i e 1 1 1 1 No ac i e 2.46 (1.20–5.03) 0.014 2.10 (0.89–4.94) 0.090 3.67 (1.21–11.09) 0.021 6.67 (1.13–39.32) 0.036 Smoking s a us Non-smoke 1 1 1 1 Smoke 0.79 (0.44–1.40) 0.421 1.46 (0.77–2.77) 0.253 0.76 (0.37–1.57) 0.460 1.43 (0.42–4.85) 0.565 Alcohol consump ion None 1 1 1 1 Mode a e (W: ≤1/day; M: ≤2/day) 0.32 (0.24–0.42) < 0.001 0.42 (0.30–0.59) < 0.001 0.18 (0.13–0.26) < 0.001 0.23 (0.13–0.42) < 0.001 Excessi e (W: > 1/day; M: > 2/day) 0.35 (0.23–0.54) < 0.001 0.51 (0.31–0.83) 0.007 0.16 (0.09–0.29) < 0.001 0.14 (0.05–0.43) 0.001 Cogni i e unc ion (MMSE) No mal 1 1 1 1 Impai ed 3.05 (1.36–6.83) 0.007 2.08 (0.83–5.20) 0.117 7.45 (3.29–16.87) < 0.001 2.62 (0.71–9.64) 0.148 Sel -pe cep ion o heal h s a us Ve y good o good 1 1 1 1 Fai 1.78 (1.36–2.32) < 0.001 1.71 (1.26–2.32) 0.001 3.38 (2.28–5.02) < 0.001 2.20 (1.21–4.00) 0.010 Poo o e y poo 7.74 (4.24–14.10) < 0.001 4.89 (2.58–9.27) < 0.001 35.91 (18.60–69.30) < 0.001 12.56 (5.18–30.47) < 0.001 BMI classifica ion (WHO) Unde weigh /No mal weigh 1 1 1 1 O e weigh 1.22 (0.86–1.71) 0.265 1.64 (1.10–2.45) 0.016 0.73 (0.48–1.12) 0.148 1.38 (0.66–2.92) 0.394 Obesi y 2.22 (1.53–3.22) < 0.001 2.70 (1.75–4.15) < 0.001 2.13 (1.38–3.29) 0.001 5.24 (2.35–11.68) < 0.001 Unde nu i ion s a us (MNA-SF) No unde nou ished 1 1 1 1 Unde nu i ion o unde nu i ion isk 2.78 (1.68–4.61) < 0.001 2.69 (1.53–4.75) 0.001 8.62 (5.13–14.49) < 0.001 16.30 (6.71–39.56) < 0.001 OR –Odds a io; CI –Confidence in e al; W –Women; M –Men; MMSE –Mini men al s a e examina ion; BMI –Body mass index; WHO –Wo ld Heal h O ganiza ion; MNA-SF –Mini nu i ional assessmen –Sho o m. A.R. Sousa-San os e al. A chi es o Ge on ology and Ge ia ics 74 (2018) 162–168 166 p e alence inc eased wi h age, which may be associa ed o he phy- siologic changes inhe en ly associa ed wi h he ageing p ocess. Ne e heless, he expec ed posi i e associa ion be ween emale gende and ail y s a us was no obse ed, e en hough women we e in a highe numbe in he p esen s udy (Colla d e al., 2012). Addi ionally, a mode a e and an excessi e alcohol consump ion was in e sely asso- cia ed wi h ail y s a us. Compa able esul s we e epo ed by a sys- ema ic e iew aimed o s udy he ela ionship be ween alcohol con- sump ion and ail y isk (Kojima, Liljas, Iliffe, Ji aj, & Wal e s, 2017). Howe e , he possibili y o e e se causali y has been poin ed ou , in which he educ ion in alcohol consump ion s a s when indi iduals become mo e ail (Kojima e al., 2017). P esen esul s show ha a lowe educa ional le el was also asso- cia ed wi h highe equency o p e- ail y and ail y. One possible explana ion o his associa ion may be he ac ha indi iduals wi h mo e educa ion ha e mo e access o in o ma ion and be e heal hy beha io awa eness, and also a highe socioeconomic s a us. Conside ing Po ugal backg ound, hese we e he indi iduals wi h a p i ileged access o educa ion. Al hough in he Ca dio ascula Heal h s udy, diffe ences ega ding educa ion le el we e no ound (Hi sch e al., 2006), simila esul s epo ed by se e al o he s udies a e in line wi h ou findings (Espinoza, Jung, & Hazuda, 2012;Hoogendijk e al., 2014;Szan on, Seplaki, Tho pe, Allen, & F ied, 2010). Plus, in he Longi udinal Aging S udy Ams e dam (LASA), i was obse ed ha low educa ion le el was associa ed wi h ail y, bu al hough he p e alence o ail y inc eased o e ime, he a e o inc ease did no a y ac oss educa ion le els (Hoogendijk e al., 2014). In he NHANES s udy, ail y p e alence was highes among obese ollowed by o e weigh pa icipan s (Smi , Win e s-S one, Lop inzi, Tang, & C espo, 2013). E en hough, p esen da a showed ha o e - weigh s a us was only associa ed wi h p e- ail y, whe eas obesi y was posi i ely associa ed wi h bo h p e- ail y and ail y. These esul s a e in line wi h da a om Women Heal h and Aging s udy (Blaum, Xue, Michelon, Semba, & F ied, 2005). Fo each BMI ca ego y, a simila pa e n o he one desc ibed o all ca ego ies conce ning he p e- alence o ail y c i e ia was obse ed (Blaum e al., 2005). In his sample, o e weigh and obese people ha e lowe physical ac i i y le- els and highe le els o exhaus ion, which can explain his associa ion as physical ac i i y and exhaus ion a e bo h c i e ia used o de e mine ail y s a us. Addi ionally, p o essionally inac i e people we e also mo e physical inac i e (da a no shown). The esul s ega ding he associa ion o p e- ail y and ail y wi h unde nu i ion s a us demons a ed ha ail olde adul s a e also mo e likely o be unde nou ished o a unde nu i ion isk. Indeed, he close associa ion be ween hese synd omes was p e iously highligh ed (Bollwein e al., 2013). I is wo h no ing ha ques ions abou weigh loss and mobili y a e included in he MNA-SF and a e simila o some ail y c i e ia. This s udy has some s eng hs. I used da a om a na ionwide sample o he Po uguese olde adul popula ion. Al hough o y- h ee indi iduals we e excluded, when included and excluded indi iduals we e compa ed, diffe ences be ween hem we e only obse ed e- ga ding he egional a ea, BMI and alcohol consump ion. E en hough, he possibili y ha he lack o s a is ical significance is ela ed wi h he low numbe o excluded indi iduals and a consequence o ype II e o canno be uled ou . The c oss-sec ional design o his s udy is a limi a ion, as we a e unable o de e mine he di ec ion o he associa ions es ablished. F ied’s c i e ia o e alua e ail y s a us was adop ed, howe e he In e na ional Physical Ac i i y Ques ionnai e was chosen ins ead o he Minneso a Leisu e Time Ac i i ies Ques ionnai e. The la e was used in he p oposed defini ion o assess physical ac i i y le els, which can lead o a ia ions in he esul s. Howe e , s udies abou his ma e a e s ill lacking. 5. Conclusion This condi ion is e y p e alen in Po uguese olde adul s, one fi h a e ail whe eas hal a e p e- ail. Ne e heless, compa ison wi h o he s udies is hampe ed by he diffe ences be ween hem. Age > 75, being p o essionally inac i e, poo sel -pe cep ion o heal h s a us, being obese and unde nou ished o a unde nu i ion isk inc eased ail y isk, whe eas a highe educa ion le el, being ma ied o li ing oge he and alcohol consump ion we e associa ed wi h a dec eased ail y isk. P e- ail and ail Po uguese olde adul s mani es low HGS as he mos p e alen c i e ion, o e o he ail y c i e ia. Conflic s o in e es The au ho s decla e no conflic o in e es . Acknowledgmen s Nu i ion UP 65 is unded by Iceland, Liech ens ein, and No way h ough Eu opean Economic A ea (EEA) G an s in 85% and by Faculdade de Ciências da Nu ição e Alimen ação, Uni e sidade do Po o in 15%. Iceland, Liech ens ein, and No way sponso ini ia i es and p ojec s in a ious p og am a eas, p ima ily ocusing on educing economic and social dispa i ies. The Eu opean Economic A ea G an s a e managed by Adminis ação Cen al do Sis ema de Saúde h ough he P og ama Inicia i as em Saúde Pública. Fig. 1. Dis ibu ion o he fi e ail y c i e ia among p e- ail and ail olde adul s. HGS –Handg ip s eng h * Cu -offpoin s: HGS –Men: ≤29 kg (BMI ≤24 kg/m 2 ), ≤30 kg (BMI 24.1–26 kg/m 2 ), ≤30 kg (BMI 26.1–28 kg/m 2 ), ≤32 kg (BMI > 28 kg/m 2 ) / Women: ≤17 kg (BMI ≤23 kg/m 2 ), ≤17.3 kg (BMI 23.1–26 kg/m 2 ), ≤18 kg (BMI 26.1–29 kg/m 2 ), ≤21 kg (BMI > 29 kg/m 2 ); Exhaus ion –Modified 10-i em CES-D (“I el ha e e y hing I did was an effo ’’ ≥3 days in he pas week o “I could no ge ‘going’” ≥3 days in he pas week); Slowness: Men: ≥7 seconds (heigh ≤173 cm), ≥6 seconds (heigh > 173 cm) / Women: ≥7 seconds (heigh ≤159 cm), ≥6 seconds (heigh > 159 cm); Low physical ac i i y –Men < 383 Kcals/week / Women < 270 Kcals/week; Unin en ional weigh loss: > 4.5 kg los unin en ionally in p io yea . A.R. Sousa-San os e al. A chi es o Ge on ology and Ge ia ics 74 (2018) 162–168 167 Appendix A. Supplemen a y da a Supplemen a y da a associa ed wi h his a icle can be ound, in he online e sion, a h ps://doi.o g/10.1016/j.a chge .2017.10.018. Re e ences Abizanda Sole , P., Lopez-To es Hidalgo, J., Rome o Rizos, L., Lopez Jimenez, M., Sanchez Ju ado, P. M., A ienza Nunez, P., e al. (2011). [F ail y and dependence in Albace e (FRADEA s udy): Reasoning, design and me hodology]. Re is a Espanola De Ge ia ia Y Ge on ologia, 46(2), 81–88. Ama al, T. F., San os, A., Gue a, R. S., Sousa, A. S., Ál a es, L., Valdi iesso, R., e al. (2016). Nu i ional s a egies acing an olde demog aphic: The Nu i ion UP 65 s udy p o ocol. JMIR Resea ch P o ocols, 5(3). Blaum, C. S., Xue, Q. L., Michelon, E., Semba, R. D., & F ied, L. P. (2005). The associa ion be ween obesi y and he ail y synd ome in olde women: The Women's Heal h and Aging S udies. Jou nal o he Ame ican Ge ia ics Socie y, 53(6), 927–934. Ble, A., Che ubini, A., Volpa o, S., Ba ali, B., Wals on, J. D., Windham, B. G., e al. (2006). Lowe plasma i amin E le els a e associa ed wi h he ail y synd ome: The InCHIANTI S udy. The Jou nals o Ge on ology Se ies A: Biological Sciences and Medical Sciences, 61(3), 278–283. Bollwein, J., Volke , D., Diekmann, R., Kaise , M. J., U e , W., Vidal, K., e al. (2013). Nu i ional s a us acco ding o he mini nu i ional assessmen (MNA ® ) and ail y in communi y dwelling olde pe sons: A close ela ionship. The Jou nal o Nu i ion, Heal h & Aging, 17(4), 351–356. Bouillon, K., Ki imaki, M., Hame , M., Sabia, S., F ansson, E. I., Singh-Manoux, A., e al. (2013). Measu es o ail y in popula ion-based s udies: An o e iew. BMC Ge ia ics, 13(1), 64. Chen, X., Mao, G., & Leng, S. X. (2014). F ail y synd ome: An o e iew. Clinical In e en ions in Aging, 9, 433–441. Chumlea, W. C., Guo, S., Roche, A. F., & S einbaugh, M. L. (1988). P edic ion o body weigh o he nonambula o y elde ly om an h opome y. Jou nal o he Ame ican Die e ic Associa ion, 88(5), 564–568. Colla d, R. M., Bo e , H., & Schoe e s, R. A. (2012). Oude Voshaa RC: P e alence o ail y in communi y-dwelling olde pe sons: A sys ema ic e iew. Jou nal o he Ame ican Ge ia ics Socie y, 60(8), 1487–1492. C aig, C. L., Ma shall, A. L., Sjos om, M., Bauman, A. E., Boo h, M. L., Ainswo h, B. E., e al. (2003). In e na ional physical ac i i y ques ionnai e: 12-coun y eliabili y and alidi y. Medicine and Science in Spo s and Exe cise, 35(8), 1381–1395. D ey, M., P ei e , K., Siebe , C. C., & Baue , J. M. (2011). The F ied ail y c i e ia as inclusion c i e ia o a andomized con olled ial: Pe sonal expe ience and li e a u e e iew. Ge on ology, 57(1), 11–18. Espinoza, S. E., Jung, I., & Hazuda, H. (2012). F ail y ansi ions in he San An onio Longi udinal S udy o Aging. Jou nal o he Ame ican Ge ia ics Socie y, 60(4), 652–660. Fess, E. (1992). Clinical assessmen ecommenda ions. Chicago: Ame ican Socie y o Hand The apis . F ied, L. P., Tangen, C. M., Wals on, J., Newman, A. B., Hi sch, C., Go diene , J., e al. (2001). F ail y in olde adul s: E idence o a pheno ype. The Jou nals o Ge on ology Se ies A: Biological Sciences and Medical Sciences, 56(3), M146–M157. Ga cia-Ga cia, F. J., Gu ie ez A ila, G., Al a o-Acha, A., Amo And es, M. S., De Los Angeles de la To e Lanza, M., Esc ibano Apa icio, M. V., e al. (2011). The p e- alence o ail y synd ome in an olde popula ion om Spain. The Toledo s udy o heal hy aging. The Jou nal o Nu i ion, Heal h & Aging, 15(10), 852–856. Ga ido, M., Se ano, M. D., Ba olome, R., & Ma inez-Vizcaino, V. (2012). [Diffe ences in he exp ession o he ail y synd ome in ins i u ionalized elde ly men and women wi h no se e e cogni i e decline]. Re is a Espanola De Ge ia ia Y Ge on ologia, 47(6), 247–253. Gonzalez-Vaca, J., de la Rica-Escuin, M., Sil a-Iglesias, M., A jonilla-Ga cia, M. D., Va ela-Pe ez, R., Oli e -Ca bonell, J. L., e al. (2014). F ail y in INs i u ionalized olde adul s om ALbace e The FINAL S udy: Ra ionale, design, me hodology, p e- alence and a ibu es. Ma u i as, 77(1), 78–84. Gue a, R. S., Fonseca, I., Pichel, F., Res i o, M. T., & Ama al, T. F. (2014). Hand leng h as an al e na i e measu emen o heigh . Eu opean Jou nal o Clinical Nu i ion, 68(2), 229–233. Gue ei o, M. (2010). Tes es de as eio de de ei o cogni i o e demência: Uma pe spec i a p á ica]. 8 26 (1). Hi sch, C., Ande son, M. L., Newman, A., Kop, W., Jackson, S., Go diene , J., e al. (2006). The associa ion o ace wi h ail y: The Ca dio ascula Heal h S udy. Annals o Epidemiology, 16(7), 545–553. Holze , B. M., Siebenhuene , K., Bopp, M., & Minde , C. E. (2014). O e coming cu -off es ic ions in mul imo bidi y p e alence es ima es. BMC Public Heal h, 14. Hoogendijk, E. O., an Hou , H. P. J., Heymans, M. W., an de Ho s , H. E., F ij e s, D. H. M., B oese an G oenou, M. I., e al. (2014). Explaining he associa ion be ween educa ional le el and ail y in olde adul s: Resul s om a 13-yea longi udinal s udy in he Ne he lands. Annals o Epidemiology, 44,e2. Ins i u o Nacional de Es a ís ica (2015). En elhecimen o da população esiden e em Po ugal e na União Eu opeia]. Ju schik, P., Nunin, C., Bo igue, T., Escoba , M. A., La edan, A., & Vilad osa, M. (2012). P e alence o ail y and ac o s associa ed wi h ail y in he elde ly popula ion o Lleida, Spain: The FRALLE su ey. A chi es o Ge on ology and Ge ia ics, 55(3), 625–631. Kojima, G., Liljas, A., Iliffe, S., Ji aj, S., & Wal e s, K. (2017). A sys ema ic e iew and me a-analysis o p ospec i e associa ions be ween alcohol consump ion and inciden ail y. Age and Ageing, 1–9. Nes le Nu i ion Ins i u e, MNA Mini Nu i ional Assessmen , 2009 [A ailable om: h p://www.mna-elde ly.com/ o ms/mini/mna_mini_po uguese.pd ]. Op he Veld, L. P. M., an Rossum, E., Kempen, G. I. J. M., de Ve , H. C. W., Hajema, K., & Beu skens F ied, A. J. H. M. (2015). pheno ype o ail y: C oss-sec ional compa ison o h ee ail y s ages on a ious heal h domains. BMC Ge ia ics, 15(1), 77. Radloff, L. S. (1977). The CES-D scale: A sel - epo dep ession scale o esea ch in he gene al popula ion. Applied Psychological Measu emen , 1(3), 385–401. Rockwood, K., Song, X., MacKnigh , C., Be gman, H., Hogan, D. B., McDowell, I., e al. (2005). A global clinical measu e o fi ness and ail y in elde ly people. CMAJ: Canadian Medical Associa ion Jou nal, 173(5), 489–495. Rome o-O uno, R., Walsh, C. D., Lawlo , B. A., & Kenny, R. A. (2010). A ail y ins u- men o p ima y ca e: Findings om he Su ey o Heal h, Ageing and Re i emen in Eu ope (SHARE). BMC Ge ia ics, 10,57. San os-Eggimann, B., Cuénoud, P., Spagnoli, J., & Junod, J. (2009). P e alence o ail y in middle-aged and olde communi y-dwelling eu opeans li ing in 10 coun ies. The Jou nals o Ge on ology Se ies ABiological Sciences and Medical Sciences, 64a(6), 675–681. Smi , E., Win e s-S one, K. M., Lop inzi, P. D., Tang, A. M., & C espo, C. J. (2013). Lowe nu i ional s a us and highe ood insufficiency in ail olde US adul s. The B i ish Jou nal o Nu i ion, 110(1), 172–178. S ewa , A., Ma ell-Jones, M., Olds, T., & Ridde , H. (2011). In e na ional s anda ds o an h opome ic assessmen Po che s oom, Sou h A ica. In e na ional Socie y o he Ad ancemen o Kinan h opome y. Szan on, S. L., Seplaki, C. L., Tho pe, R. J., Allen, J. K., & F ied, L. P. (2010). Socioeconomic s a us is associa ed wi h ail y: The Women’s Heal h and Aging S udies. Jou nal o Epidemiology and Communi y Heal h, 64(1), 63–67. Viei a, A. I., Noguei a, D., de Aze edo Reis, E., da Lapa Rosado, M., Vania Nunes, M., & Cas o-Caldas, A. (2016). Hand ac ile disc imina ion, social ouch and ail y c i e ia in elde ly people: A c oss sec ional obse a ional s udy. A chi es o Ge on ology and Ge ia ics, 66,73–81. Xue, Q. L., Bandeen-Roche, K., Va adhan, R., Zhou, J., & F ied, L. P. (2008). Ini ial mani es a ions o ail y c i e ia and he de elopmen o ail y pheno ype in he Women's Heal h and Aging S udy II The Jou nals o Ge on ology Se ies A. Biological Sciences and Sedical Sciences, 63(9), 984–990. Xue, Q. L. (2011). The ail y synd ome: Defini ion and na u al his o y. Clinics in Ge ia ic Medicine, 27(1), 1–15. A.R. Sousa-San os e al. A chi es o Ge on ology and Ge ia ics 74 (2018) 162–168 168