Scientists have shown that social frailty – a composite index based on income level, household status, and social activity – significantly affects all-cause mortality in the elderly, with poverty being the predominant factor [1].
There is more than one way to be frail
Physical frailty is a known companion of aging and a major risk factor for several age-related diseases [2]. As such, it gets a lot of attention from the longevity community. However, there is another type of frailty that usually evades the spotlight: social frailty. This rather novel concept is defined as “the absence of social resources, social activities, and self-management abilities that are important for fulfilling basic social needs” [3]. In other words, it is mostly about poverty, disability, and loneliness. In this new study, a group of European scientists argues that social frailty is a potent predictor of all-cause mortality in the elderly.
While it has been long known that poverty is significantly inversely correlated with health and longevity [4], the COVID pandemic has highlighted the adverse effects of a lack of social interaction. Several studies have shown that older people who were socially isolated during the lockdowns were also significantly more likely to develop cognitive impairment than those who were able to maintain social activity.
Some previous studies have already documented high prevalence of social frailty among older adults suffering from dementia, memory decline, and cognitive impairment, but those studies suffered from limitations such as small sample sizes [5]. This time, the researchers used data from the English Longitudinal Study of Ageing (ELSA) regarding over 4,000 elderly people, with a relatively long follow-up of 10 years.
Money or friends? Better have both
The social frailty index used by the researchers was based on income (UK poverty threshold of £20,346 per household per year), household status (living alone or not), participation in social activities, and contacts with friends (at least once a week in person, over the phone, or by email). For each risk factor a participant got a score of either 1 or 0. Social frailty was defined as 2 or more points, pre-frailty as 1 point, and a total absence of risk factors (robustness) as 0 points.
Of course, in such studies, everything revolves around the chicken and egg dilemma. It could be, for instance, that health is negatively influenced by the lack of social interactions, the other way around, or a bi-directional relationship. In addition to the long follow-up period, the researchers tried to increase the robustness of the study by controlling for several important variables: age, sex, education, marital status, body mass index, smoking status, disability, levels of physical activity, the presence of comorbidities, race, and depression symptoms.
Social frailty: highly prevalent
As it turns out, social frailty is highly prevalent among English elderly: it affected 43% of the participants. 39% were categorized as pre-frail, and only 18% as robust. The most frequent problem was poverty, experienced by 64.5% of the participants, and the least frequent was living alone (15.4%).
Unsurprisingly, social frailty was found to be positively correlated with age, lack of physical activity, obesity, smoking, and multimorbidity (numerous health problems). Interestingly, women were much more susceptible to social frailty. We can only speculate about the reasons, but it might be an echo of the gender income gap, which was much wider when the participants were in their productive years than it is today.
In a model fully adjusted for covariates, social frailty significantly correlated with all-cause mortality with a hazard ratio of 1.31 (that is, socially frail people were 31% more likely to die of any cause). When standalone elements of the social frailty index were analyzed, poverty emerged as an even more powerful predictor of mortality, with a hazard ratio of 1.60, while living alone came in second with 1.46.
Our study shows the importance of the issue of social frailty for geriatrics and general practitioners. Research on social frailty could be useful to prevent the onset of pathologies that can cause death in older people. We may suggest that as measures to early detect and prevent social frailty, the implementation of easy accessibility and limited costs by the national health systems may be of help also allowing better use of resources. Therefore, every government should have in its welfare program a scheme to avoid social frailty, and in particular, poverty and living alone for older people.
Conclusion
Despite all their drawbacks, population studies can raise important questions and draw attention to consequential issues. For instance, we can see that even in a country with universally accessible healthcare, poverty remains a major risk factor for all-cause mortality. The COVID pandemic has highlighted the importance of social interactions for our health and the vulnerability of the elderly, as this study confirms. More research is needed to further investigate the correlations revealed in this and similar studies, such as the role of gender.
Literature
[1] Ragusa, F. S., Veronese, N., Smith, L., Koyanagi, A., Dominguez, L. J., & Barbagallo, M. (2022). Social frailty increases the risk of all-cause mortality: A longitudinal analysis of the English Longitudinal Study of Ageing. Experimental Gerontology, 111901.
[2] Thillainadesan, J., Scott, I. A., & Le Couteur, D. G. (2020). Frailty, a multisystem ageing syndrome. Age and ageing, 49(5), 758-763.
[3] Ma, L., Sun, F., & Tang, Z. (2018). Social frailty is associated with physical functioning, cognition, and depression, and predicts mortality. The journal of nutrition, health & aging, 22(8), 989-995.
[4] Chetty, R., Stepner, M., Abraham, S., Lin, S., Scuderi, B., Turner, N., … & Cutler, D. (2016). The association between income and life expectancy in the United States, 2001-2014. Jama, 315(16), 1750-1766.
[5] Ong, M., Pek, K., Tan, C. N., Chew, J., Lim, J. P., Yew, S., … & Lim, W. S. (2022). Social frailty and executive function: Association with geriatric syndromes, life space and quality of life in healthy community-dwelling older adults. The Journal of Frailty & Aging, 11(2), 206-213.
