Study On The Development Trajectories And Influencing Factors Of Symptom Clusters Of The Frail Elderly In Institutionalized In Chengdu

ObjectivesOn the basis of the study on the symptom clusters of the elderly with frailty in pension institutions,and under the theoretical guidance of the Symptoms Experiencein in Time Model and Chronic Illness Trajectory Model,this study explores the symptom cluster patterns of the elderly with frailty in pension institutions in China at different time points（baseline,6 months,12 months）,so as to provide a new perspective for the management of clinical symptom clusters;to fit the category trajectory of the frail elderly in pension institutions,so as to provide reference for accurate prevention and scientific management of symptom clusters;to determine the role of baseline-related factors in predicting the trajectory categories of symptom clusters of the frail elderly in pension institutions,so as to provide a basis for finding targeted and specific intervention programs in the future.MethodsThe longitudinal study design was used in this study.From November 2019 to January 2020,6 pension institutions in Chengdu were selected by convenience sampling,and 253 frail elderly people who met the inclusion and exclusion criteria were selected by convenience sampling（this study is based on the Latent Growth Mixture Model statistical method,taking into account the actual maneuverability in the process of data collection,pre-survey and 20%loss of follow-up rate,and finally determined that the sample size）.The first baseline data collection（T₀）:face-to-face on-the-spot survey was conducted,Frailty Phenotype was used to evaluate the frailty state of the elderly with a score of 3,and 253 subjects were included in the study.Then the self-designed questionnaire was used to collect the social demographic data and health-related factors of the frail elderly in pension institutions.Memorial Symptom Assessment Scale was used to evaluate the symptoms of the elderly,and the baseline data were established.The second and third follow-up data collection（T₁,T₂）:data collection methods include face-to-face on-the-spot investigation and telephone contact.The patients were followed up every 6 months for a total of 2 times.The MSAS scale was used to collect the occurrence of symptoms in the last week.Results1.Completion of follow-up and reasons for loss of follow-upA total of 253 frail elderly people were collected during the baseline survey.After12 months of follow-up,47 cases lost follow-up,including 11 cases of death,10 cases of hospitalization,and 26 cases of elderly people who could not be contacted after left or refused to participate in the follow-up for some reason,and the cumulative loss of follow-up rate was 18.58%.Finally,206 frail elderly people completed three surveys.2.Occurrence of symptoms in frail elderly in pension institutions at different time points（1）Occurrence of symptoms in T₀:at baseline,the elderly with frailty pension institutions experienced an average of（11.05±5.40）symptoms at the same time,and the median number of symptoms was 11.The top 5 symptoms were forgetfulness（73.12%）,pain（65.61%）,lack of energy（59.68%）,difficulty sleepling（57.31%）,depression/low mood（56.92%）.The top 5 scores of symptom severity were forgetfulness（1.82±1.32）,pain（1.61±1.37）,difficulty sleepling（1.54±1.54）,lack of energy（1.44±1.40）and depression/low mood（1.16±1.19）.The top five scores of symptom disturbance were forgetfulness（1.52±1.18）,pain（1.40±1.24）,difficulty sleepling（1.39±1.41）,lack of energy（1.24±1.28）and depression/low mood（0.98±0.98）.（2）Occurrence of symptoms in T₁:at 6 months,the elderly with frailty pension institutions experienced an average of（8.99±5.44）symptoms at the same time,and the median number of symptoms was 8.The top 5 symptoms were forgetfulness（64.76%）,difficulty sleepling（60.79%）,lack of energy（48.90%）,lack of appetite（47.58%）and loneliness（46.26%）.The top five points of symptom severity were difficulty sleepling（1.49±1.39）,forgetfulness（1.41±1.25）,lack of energy（1.05±1.21）,lack of appetite（1.02±1.13）and pain（1.01±1.42）.The top five scores of symptom disturbance were difficulty sleepling（1.32±1.23）,forgetfulness（1.27±1.09）,pain（0.92±1.30）,lack of energy（0.92±1.05）and lack of appetite（0.85±0.95）.（3）Occurrence of symptoms in T₂:at 12 months,the average number of symptoms experienced by the elderly with frailty pension institutions was（10.40±6.83）,and the median number of symptoms was 9.The top 5 symptoms were forgetfulness（74.76%）,skin itching（67.96%）,pain（61.17%）,difficulty sleepling（59.71%）and constipation（51.94%）.The top five severity of symptoms were forgetfulness（1.76±1.27）,pain（1.52±1.36）,difficulty sleepling（1.51±1.41）,skin itching（1.51±1.18）and constipation（1.18±1.26）.The top five scores of symptom disturbance were forgetfulness（1.61±1.18）,pain（1.38±1.30）,difficulty sleepling（1.36±1.31）,skin itching（1.30±1.05）and constipation（0.97±1.05）.3.Symptom clusters of the frail elderly in pension institutions at different time points（1）Two core symptom clusters were formed at T₀:six factors were extracted by exploratory factor analysis:（1）psychological symptoms:depression/low mood,loneliness,anxiety,sadness;（2）neurological symptoms:pain,tinnitus,vertigo,numbness/tingling in hands/feet,skin itching;（3）energy deficiency symptoms:difficulty sleeping,lack of energy,difficulty concentrating,feeling drowsy;（4）respiratory symptoms:dry mouth,cough;（5）gastrointestinal symptoms:food taste change,constipation,lack of appetite;（6）aging-related symptoms:forgetfulness,masticatory difficulty,hair loss.Among them,neurological symptoms,energy deficiency symptoms,respiratory symptoms,gastrointestinal symptoms and aging-related symptoms belong to physical frality symptom clusters,and the contribution rates of variance are 9.245%,6.960%,5.992%,5.580%and 4.969%,respectively.Psychological symptoms belong to psychological frailty symptom clusters,the contribution rate of variance is 17.941%.（2）Two core symptom clusters were formed at T₁:six factors were extracted by exploratory factor analysis:（1）neurological symptoms:numbness/tingling in hands/feet,pain,tinnitus,vertigo,feeling drowsy;（2）psychological symptoms:loneliness,depression/low mood,sadness,irritability,anxiety;（3）gastrointestinal symptoms:food taste change,lack of appetite,constipation,difficulty sleeping;（4）respiratory symptoms:cough,skin itching,shortness of breath;（5）energy deficiency symptoms:lack of energy,difficulty concentrating,hair loss,dry mouth;（6）aging-related symptoms:forgetfulness,masticatory difficulty.Among them,neurological symptoms,gastrointestinal symptoms,respiratory symptoms,energy deficiency symptoms and aging-related symptoms belong to physical frailty symptom clusters,and the variance contribution rate is 23.250%,6.501%,6.460%,5.732%,4.744%respectively.Psychological symptoms belong to psychological frality symptom clusters,the contribution rate of variance is 8.652%.（3）Two core symptom clusters were formed at T₂:six factors were extracted by exploratory factor analysis:（1）psychological symptoms:loneliness,sadness,depression/low mood,anxiety;（2）energy deficiency symptoms:difficulty concentrating,dry mouth,feeling drowsy,lack of energy;（3）other symptoms:difficulty sleeping,skin itching,constipation;（4）neurological symptoms:numbness/tingling in hands/feet,pain,vertigo;（5）aging-related symptoms:lack of appetite,food taste change,tinnitus,forgetfulness;（6）respiratory symptoms:shortness of breath,cough.Among them,energy deficiency symptoms,other symptoms,neurological symptoms,aging-related symptoms and respiratory symptoms belong to physical frality symptom clusters,and the contribution rates of variance are 8.762%,7.280%,7.069%,5.917%and 5.416%,respectively.Psychological symptoms belong to psychological frality symptom clusters,and the contribution rate of variance is 22.019%.（4）Changes of symptom clusters at different time points:there were two core symptom clusters:physical frality symptom clusters and psychological frailty symptom clusters at three time points.Among them,neurological symptoms,energy deficiency symptoms,respiratory symptoms,gastrointestinal symptoms,aging-related symptoms and other symptoms belong to physical frality symptom clusters,and psychological symptoms belong to psychological frality symptom clusters.There were changes in the composition and number of symptoms in each symptom clusters,in which neurological symptoms,energy deficiency symptoms,respiratory symptoms,gastrointestinal symptoms and psychological symptoms persisted at three time points.Aging-related symptoms appeared at T₀ and T₁.Other symptoms appear at T_2.The results of repeated measurement analysis of variance showed that there were significant differences in the severity of symptoms and symptom clusters at different time points（P<0.05）.4.Changes of symptom clusters trajectory of the frail elderly in pension institutions（1）Physical frailty symptom clusters trajectory:there are heterogeneous trajectories of physical frailty symptom clusters of the frail elderly in pension institutions,showing four trajectories of"high decline","low rise","medium maintenance"and"medium rise".Among them,the proportion of the elderly with"medium maintenance"trajectory is the highest,which is 66.0%,and the proportion of the elderly with"high decline"and"low rise"trajectories are similar,which are 16.5%and 12.5%,respectively.The proportion of the elderly in the"medium rise"trajectory is the lowest,at 5.0%.（2）Psychological frailty symptom clusters trajectory:there are heterogeneous trajectories of psychological frailty symptom clusters of the frail elderly in pension institutions,showing two trajectories of"low maintenance"and"high rise",of which the elderly with"low maintenance"trajectory account for 93.8%,and the elderly with"high rise"trajectory account for 6.2%.（3）Physical and psychological frailty symptom clusters trajectory:there are heterogeneous trajectories of physical and psychological frailty symptom clusters of the frail elderly in pension institutions,showing three trajectories of"low rise","high decline"and"medium maintenance".Among them,the elderly with"low rise"trajectory accounted for 26.2%,the elderly with"high decline"trajectory accounted for16.0%,and the elderly with"medium maintenance"trajectory accounted for 57.8%.5.Predictor factors of symptom clusters trajectory of the elderly with frailty in pension institutions（1）Physical symptom clusters:the results of disordered multi-classification logistic regression analysis showed that compared with the elderly with more than 10 chronic diseases,the elderly with 1～3 diseases were more likely to appear in the"low rise"trajectory than in the"high decline"（OR=48.197,P=0.046）and"medium rise"（OR=0.015,P=0.043）trajectories.The elderly with 1～3,4～6,7～9 diseases were more likely to appear in the"medium maintenance"trajectory than in the"high decline"（OR=25.521,P=0.002;OR=8.688,P=0.014;OR=9.117,P=0.020）and"medium rise"（OR=0.028,P=0.007;OR=0.024,P=0.002;OR=0.011,P=0.001）trajectories.Compared with the elderly who took more than 5 kinds of medicines,the elderly who did not take medicines were more likely to appear in the"low rise"trajectory（OR=0.038,P=0.028）than in the"medium rise"trajectory,and the elderly who took 1～2 kinds of medicines were more likely to appear in the"medium maintenance"trajectory（OR=0.111,P=0.025）than in the"medium rise"trajectory.That is to say,the chronic diseases of the frail elderly in pension institutions are the independent predictors of"high decline"and"medium rise"trajectories,and the type of medication is the independent predictor of"medium rise"trajectory.（2）Psychological frailty symptom clusters:the results of binary logistic regression analysis showed that education level（OR=0.057,P=0.042）,number of children（OR=0.024,P=0.004）and self-rated health status（OR=0.065,P=0.029）were the influencing factors of heterogeneity of psychological symptom clusters in elderly people with frailty in pension institutions.（3）Physical and psychological frailty symptom clusters:the results of disordered multi-classification logistic regression analysis showed that compared with the elderly who took more than 5 kinds of medicines,the elderly with 1～2 kinds of medicines were more likely to appear in the"medium maintenance"（OR=3.716,P=0.042）trajectory than in the"low rise"trajectory.Compared with the elderly who had no history of stress in the past year,the elderly with a history of stress were more likely to appear in the"high decline"（OR=6.447,P=0.002）and"medium maintenance"（OR=2.976,P=0.016）trajectories rather than"low rise"trajectory.Compared with the elderly with good self-rated health,the elderly with poor self-rated health are more likely to appear in the"high decline"（OR=12.620,P=0.008）and"medium maintenance"（OR=11.918,P=0.003）trajectories rather than"low rise".Compared with the elderly who are dissatisfaction with living environment,the elderly with high residence satisfaction are more likely to appear in the"low rise"（OR=0.037,P=0.016）trajectory than in the"high decline"trajectory.That is to say,the type of medication taken by the frail elderly in pension institutions is an independent predictor of"low rise"trajectory,and the history of stress in the past year is an independent predictor of"high decline"and"medium maintenance"trajectories.Poor health status is an independent predictor of"high decline"and"medium maintenance"trajectories,and dissatisfaction with living environment is an independent predictor of"high decline"trajectory.Conclusions1.The frail elderly in pension institutions experience a variety of symptoms at the same time.The frequency,severity and disturbance of symptoms at T₀,T₁ and T₂ are different,and the symptoms that need to be detected and controlled at different time points are different.Among them,the frequency,severity and disturbance of forgetfulness are higher at three time points,and the symptom burden on the elderly is the heaviest.2.The symptoms of the frail elderly in pension institutions influence each other and can be clustered into groups through exploratory factor analysis.Two core symptom clusters were formed at T₀,in which neurological symptoms,energy deficiency symptoms,respiratory symptoms,gastrointestinal symptoms and aging-related symptoms belong to physical frality symptom clusters,and psychological symptoms belong to psychological frality symptom clusters.Two core symptom clusters were formed at T₁.Among them,neurological symptoms,gastrointestinal symptoms,respiratory symptoms,energy deficiency symptoms and aging-related symptoms belong to physical frality symptom clusters,and psychological symptoms belong to psychological frality symptom clusters.Two core symptom clusters were formed at T₂,in which energy deficiency symptoms,other symptoms,neurological symptoms,aging-related symptoms and respiratory symptoms belong to physical frality symptom clusters,and psychological symptoms belong to psychological frality symptom clusters.The number and internal composition of symptoms in the symptom clusters of the elderly with frality in pension institutions are different at different time points,and the severity of each symptom in the symptom clusters is also different.3.There are heterogeneity trajectories in three symptom clusters:physical frality symptom clusters,psychological frality symptom clusters,physical and psychological frality symptom clusters of the elderly with frailty pension institutions.The physical frailty symptom clusters showed four trajectories of"high decline","low rise","medium maintenance"and"medium rise",and 66.0%of the elderly showed the"medium maintenance"trajectory.It shows that the severity of symptoms in the frail elderly in most pension institutions remains at a high level and is in urgent need of improvement.The psychological frailty symptom clusters showed two trajectories of"low maintenance"and"high rise",and 93.8%of the people showed a trend of"low maintenance".It shows that the psychological state of the vast majority of the elderly is at a stable level within one year.The physical and psychological frality symptom clusters showed three trajectories of"low rise","high decline"and"medium maintenance",of which the number of"medium maintenance"accounted for 57.8%at most.Suggesting that managers of pension institutions should give effective intervention measures as soon as possible to improve the severity of the symptoms.4.The chronic diseases of the frail elderly in pension institutions are the independent predictors of the"high decline"and"medium rise"trajectories of physical frality symptom clusters within one year,and the kinds of medication are the independent predictors of"medium rise"trajectory.education,number of children and self-rated health status are independent predictors of heterogeneity of psychological symptom clusters within one year.The independent predictors of the"low rise"trajectory of physical and psychological frality symptom clusters within one year after taking more than one year of medication,and the history of stress in the past year is the independent predictor of"high decline"and"medium maintenance"trajectories.poor health status is an independent predictor of"high decline"and"medium maintenance"trajectories,and dissatisfaction with residence is an independent predictor of"high decline"trajectory.