Athlete older women and sedentary controls: compairing the incidence of frailty, physical aspects and falls

Introduction: The aging process results in falls, frailty, and functional dependence. However, the practice of physical exercises can prevent negative impacts on the older adult health. Objective: To compare the incidence of frailty, physical aspects, and number of falls among older adult women and sedentary controls. Methods: The study has a cross-sectional design and included 70 community-dwelling older adult women (73.96±7.52 years). The frailty phenotype (Fried Criteria) and the history of falls in the last 12 months were analyzed, followed by the evaluation of muscle power (Five times Sit-to-Stand Test), functional mobility (Time Up and Go), balance (Mini BESTest) and fear of falling (Falls Efficacy Scale). The Mann Whitney and Chi-Square tests were used for statistical analysis. Results: The frailty rate among sedentary women (Pre-frail: 42.9%; Frail: 57.1%) was different from athlete women (Non frail: 100%). The rate of falls was the same in both groups (25.7%), however, sedentary controls fell at home (100%), while older adult athlete women fell in sports activities (88.9%). The athletes showed better scores (p<0.001) in all physical aspects when compared to the sedentary controls in muscle power (11.25 vs 24.10 seconds), functional mobility (10.01 vs. 16.04 seconds), balance (27 vs 19 points) and fear of falling (16 vs 27 points). Conclusion: Ahlete older women had lower frailty rates and fear of falling, as well as better physical aspects. The characteristics of falls were different, indicating the need and the importance of contemplating the lifestyle in prevention programs promoting healthy life for older adults.


INTRODUCTION
In recent years (2000-2019), the world population has shown a new demographic pattern, characterized by a reduction in the population growth rate and an increase in the number of old people. The forecast for the older adult population by 2050 is to double the current population, from 900 million to approximately 2 billion older adults 1 .
Global aging will place a greater focus on the health system, impacting it socially and financially as, over the years, older adults become more susceptible to illnessess and/or dependence 2 . This information is evidenced with the study of the aging process, Silva  The frailty syndrome can be defined as a decrease in energy reserves and reduced resistance to stressors, which results in the decline of physiological systems 2,5 . Frailty can be detected using the five criteria, according to Fried et al. 5 , in which the older adult woman who have none of them is considered non-frail, between 1 or 2 criteria -pre-frail; and 3 or more -frail.
Literature reports that the practice of physical exercises is an important measure to prevent the frailty syndrome 5 . Physical exercise programs for health promotion are crucial to minimize the deleterious effects of aging. Despite the high number of sedentary older women, there is an increase of those who practice sports activities regularly, that is, the master athletes, being considered from the age of 35 or over 6 .
It is considered relevant to emphasize that master athletes recognize their own potential, being demanding with results in their sport and having responsibility for their health, this allows them to have lower levels of frailty, better physical and cognitive aspects than sedentary older women.
Therefore, this study aimed to compare the incidence of frailty, physical aspects and number of falls between athlete older women and sedentary controls aged 65 years and over.

Study design and population
The study has a cross-sectional character and was carried out with older women recruited from the Uberaba neighborhood, The following inclusion criteria were applied: (i) Women aged 65 years or over, (ii) insufficiently active (below 150 minutes of weekly physical activity -Sedentary group) (iii) practitioners of sport activities weekly in the last two years -Athlete group.
The exclusion criterion was: (i) women with neurological and/or cognitive changes that made it impossible to perform functional tests, complete questionnaires or understand the guidelines. These criteria were identified by means of the Mini-Mental State Examination (MMSE) classified according to the level of education. In addition, women who did not complete all assessment steps were excluded from the study. The selection of only female participants was due to low male adherence, so, in order to avoid interference or confounding factors in the data analysis, only women were selected for the present study.
All criteria were identified through the initial screening carried out by the research team. At the end of the study, 77 older women were evaluated, seven of whom were excluded because they did not complete all the evaluation steps or because they did not reach the minimum score in the MMSE. The older women were distributed in their respective groups (sedentary or athletes), according to their level of physical activity, and each group was composed of 35 individuals.

Research instruments
The evaluations were carried out in the following order: evaluation form and history of falls, identification of the frailty phenotype, cognitive status for screening decreased cognition, muscle power test (sit and stand 5 times), functional mobility test (TUG), balance test (Mini BESTest) and scale of falls effectiveness.

Evaluation form
This form was composed of open and closed questions, related to identification data, sociodemographic characteristics, clinical and health conditions of the older adults. To assess the history of falls, women were asked about the occurrence of falls in the last 12 months, including aspects related to the location, frequency, and the consequences of the fall.

Screening for frailty phenotype
To identify frailty, its phenotype was used, composed of five items: reduced handgrip strength, self-reported exhaustion, decreased level of physical activity, self-reported weight reduction and low gait speed 5,7 . The older women who did not present any positive items were considered non-frail; scores on 1 or 2 items were considered pre-frail; and if she scored more than 3 items, she was considered frail 5 . visual constructive capacity. The score ranges from zero (0) to thirty (30). This test was performed to identify individuals with cognitive loss, according to the inclusion criteria 8,9 .

Muscle power
The function of sitting and standing is among the activities of daily living most executed and its performance shows a direct relationship with the risk of falls and with the difficulty of standing after a fall, as it assesses the muscle power of the lower limbs 10,11 . In order to evaluate such activity, the sit and stand test was used five times, which consists of the time required for the participant to perform the movement of getting up and sitting in a chair five times 10,11 .

Functional mobility
The

Balance: Mini BESTest
Mini BESTest, short for Balance Evaluation Systems Test (BESTest), was designed to assess functional balance 14,15 .
This test has 14 items, scored from zero to two, and focuses on the assessment of the dynamic balance construct. The maximum score can reach 32 points, where the highest score shows greater balance 14 .

Fear of falling: Fall Effectiveness Scale
The Falls Effectiveness Scale is an instrument to assess the fear of falling during the performance of activities of daily living, external activities and social gatherings. The scale has 16 activities, with respective scores from one to four in each item. The total score can range from 16 (no concern about falling) to 64 (extreme concern about falling) 16 .

Data analysis
In the Kolmogorov-Smirnov test, the data have a non-normal distribution and, therefore, non-parametric tests were used.

RESULTS
The present study was composed of 70 women aged 73.96±7.52 years. Most older women had between 1 and 4 years of schooling (41.4%), widows (52.9%), consuming between 1 and 2 medications (47.1%) and not falling (60%). However, it is worth mentioning that 40% of the evaluated older women suffered at least one fall in the last twelve months (Table 1).
When comparing the frailty and the incidende of falls, it was possible to observe that sedentary older women had a higher prevalence of frailty and pre-frailty when compared to athlete older women. Regarding falls, there was no significant difference, indicating an equal number between the two groups ( Table 2).
In the comparison between the older women regarding physical aspects and falls, it was possible to observe a significant difference in the analyzed variables (p <0.05). The athlete older women presented lower consumption of medication, higher level of weekly  physical activity, less fear of falling and better physical aspects (balance, handgrip strength, muscle power, functional mobility and gait speed) when compared to sedentary older women (Table 3).

DISCUSSION
This study was designed to compare the incidence of frailty, physical aspects and the number of falls between athlete older women and sedentary older women aged 65 and over. The main finding is that sedentary older women presented a higher frailty index when compared to athlete older women. In addition, the athlete older women had better scores in physical aspects.
However, the number of falls in both groups was the same (25.7%), with a high rate of falls among the study participants. It is known that one third of the older adults who live in the community experience at least one episode of fall each year, which is close to the prevalence found in the present study for the general sample (40%) [19][20][21] . Falls may be responsible for the dependence and loss of autonomy of the older adults, as it usually compromises their functional capacity, which is directly related to changes resulting from aging, whether anatomophysiological or psychological 20 .
The number of falls was the same among the groups, but the sedentary older women fell in a residential environment, while the athletes fell outside, when performing sport activities.
During games or competitions, older athletes are exposed to risk situations for falls, however, they have a good physical profile, recovering quickly from these episodes, without physical or emotional consequences 22 .
Regarding walking, which generates less confidence, depression, worsening health conditions, sedentary lifestyle, social isolation and is capable of affecting the behavior of the older adults. In addition, most active older women leave home more, have greater social involvement, and during the assessment it was possible to observe that they have a greater desire to live and are sometimes During locomotion and performing activities of daily living, it is extremely important to have a good balance to promote the necessary postural adjustments 26,27 . In the present study, athlete older women showed better balance than sedentary older women.
Similar studies demonstrate that the practice of physical exercises can help the older adults in improving balance and postural control, by promoting the proper interaction of the musculoskeletal system and adequate sensory information 26,27. In this study, it was observed that athlete older women reached higher levels of muscle strength and power when compared to sedentary ones. In the study by Martin et al. 28 it was revealed that individuals who maintain high levels of handgrip strength in middle age are less likely to have functional disability when they are elderly. Studies indicate that the practice of physical exercises is directly related to muscle strength, and it is possible to note that sedentary older people have low levels of muscle strength 28 .
The reduction of handgrip strength is capable of affecting basic daily life activities, as soon as people use our hands to perform most of these, such as carrying bags, personal hygiene, preparing meals, food, among others 28 .
In relation to muscle power, which involves aspects related to the strength and speed of movement, studies confirm that the practice of physical exercises proved to be an excellent alternative for the maintenance or improvement of these aspects, because in addition to the global alteration of all systems during aging, there is a decrease especially in muscle strength and power, which negatively affects the individual's posture, balance and functional performance, increasing the risk of falls, decreasing gait speed and reducing independence in activities of daily living 28,29 . The regular practice of physical exercises shows a high potential to minimize the negative effects of aging or its associated factors, such as the cycle of immobility-falls, pain, fear-immobility, being an important control of the health of the older adult through strategies primary prevention 30,31 .
Finally, the older athletes had better functional mobility and gait speed when compared to sedentary ones. Regular physical exercise contributes positively to maintaining physical fitness, especially muscle strength and power, which are directly linked to aspects related to gait and contribute to reducing functional limitations of the older adults 30,31 .
In conclusion, it was possible to observe that the older athletes had lower rates of frailty and fear of falling, as well as better physical aspects, such as balance, muscle strength and power, functional mobility and gait speed, aspects that are fundamental for the performance on activities of daily living. However, despite the data analysis showing the same number of falls among the older women, the athletes presented the episodes of falls during sports practice, while the sedentary older women fell in their residential environment, reinforcing the difference between the profile of these older adults.
This observation highlights the need and importance of prevention programs that address not only physical exercise, but also provide information through educational programs on the importance of a healthy lifestyle and fall prevention mechanisms in different settings that involve specific activities and lifestyle habits of the older adults whether they are sports activities or their basic or instrumental daily activities, thus promoting an active and healthy lifestyle regardless of the profile of the older adults.