frailty is a common issue facing older adults , their families , and society in general .
frailty predicts adverse outcomes such as death , worsening functional status , and institutionalization . while there are numerous definitions and theoretical models of frailty , all agree that frailty is associated with increasing vulnerability and a reduced reserve to deal with stressors . to date , a large body of literature has accumulated on the adverse outcomes of frailty , the theoretical framework and definitions of frailty , and the physical and medical predictors of frailty .
there has been research into psychological and social predictors of frailty , but further inquiry into social and psychological predictors of frailty is needed . the attitude to aging and disability
health beliefs , such as locus of control , predict a wide variety of adverse health outcomes : death , health service utilization , and heart disease .
williamson and fried have shown that the belief that disability is due to aging is strongly associated with walking speed , disability , and medical conditions .
the authors conclude that  identifying and reducing the impact of these conditions may prove to be a useful approach to preventing or minimizing functional loss  . in the work done by the study of osteoporosis fractures group , this association was also present .
the authors went on to find that those who attributed poor mood to aging were less likely to seek medical care .
the study of osteoporosis fractures consisted entirely of women , and the study by williamson and fried was also predominantly female .
in addition , the temporal nature of the association is not clear ; those with disability may feel that their disability is due to aging .
conversely , the sense that disability is due to aging may change their behaviours , and engage in less healthy behaviours , or be less likely to engage in activities which maintain their health .
this may be a marker of someone who is in the early phases of frailty , and may be a  warning sign  of impending frailty .
this belief may result in behaviours which predispose to frailty , such a lower levels of physical activity or lower levels of social engagement .
seeing poor outcomes as inevitable may cause older adults to simply accept frailty rather than attempting measures to prevent it .
we have , therefore , conducted a secondary analysis of an existing cohort study , the manitoba study of health and aging ( msha ) , in order to determine if the belief that discomfort and disability are due to aging . specifically ,
the objectives of these analyses are : 
 to determine if accepting disability as a part of aging is associated with frailty in older adults living in the community ; andto determine if accepting disability as a part of aging is associated with becoming frail over a five - year period in older adults who are not frail . to determine if accepting disability as a part of aging is associated with frailty in older adults living in the community ; and to determine if accepting disability as a part of aging is associated with becoming frail over a five - year period in older adults who are not frail .
we conducted a secondary analysis of the manitoba study of health and aging ( msha ) , a population - based study conducted in the canadian province of manitoba , done in conjunction with the canadian study of health and aging ( csha ) .
the original aims of this study were to determine the prevalence and risk factors for dementia in manitoba , and to examine social correlates of aging . in 1991/1992 ,
the original sampling frame was from a list provided by manitoba health , the provincial ministry of health .
since health - care coverage is universal in manitoba , this represents a comprehensive representative sampling frame .
older age groups ( over 85 ) were over - sampled , and sampling was stratified by region , with representation from the entire province .
persons residing in institutions ( nursing homes and chronic care hospitals ) did not undergo the screening interview and were not included in these analyses .
initially , 2,890 persons were selected . of these , 443 refused to participate , 480 were not eligible ( had died , had entered a nursing home , or were too ill ) , 162 could not be located , and 54 did not complete the screening questionnaire .
the final sample at time 1 was 1,751 . at time 1 , 1,735 had no missing variables for health beliefs .
the follow - up sample included those who had survived to 1996/7 , who underwent the screening questionnaire with complete data at time 2 , who were living in the community , and who agreed to participate in the study ( n = 1,028 ) . those who were living in institutions at time 2 were excluded since they did not undergo the screening questionnaire . in manitoba ,
nursing homes are not used for convalescence , and those in institutions are very frail . for the prospective analyses , we excluded those who were frail at time 1 , leaving a final sample of 851 .
there were too few participants with mild / moderate frailty who survived and were living in the community to determine if attitudes to disability and aging predicted becoming more frail .
the research was approved by the research ethics committee of the faculty of medicine of the university of manitoba , and adhered to the declaration of helskinki .
data gathered were : age , gender , educational level ( years of education ) , and marital status .
income security was measured with the item :  how do you think your income and assets satisfy your needs ?  and was scored as :  very well / adequately / with some difficulty / not very well / totally inadequately .  we considered this as a continuous measure .
since it was not normally distributed and some cells contained few observations , we also considered it as a dichotomous variable in sensitivity analyses .
these results were similar , and we present the models with this variable included as a continuous factor .
the modified mini - mental state examination ( 3ms ) was used as the screening test for cognitive impairment and dementia .
those who scored less than 78 on the 3ms were invited to participate in a clinical examination to determine the presence of cognitive impairment or dementia .
those with cognitive impairment not meeting these criteria were diagnosed with cognitive impairment no dementia ( cind ) .
this is a heterogeneous group of people with different conditions and circumstances interfering with cognition .
participants were asked about their ability to perform basic activities of daily living ( adl ; eating , dressing , grooming , getting in and out of bed , taking a bath or shower , and ability to use the bathroom ) , instrumental activities of daily living ( iadl ; using the telephone , getting to places out of walking distance , going shopping , preparing meals , doing housework , taking medication[s ] , managing money ) , and ambulation .
the item :  when you reach my age , you have to accept a fair degree of discomfort and physical disability  was asked and scored on a five - point scale .
since there were few people who answered  mixed  and the data were not normally distributed , we also dichotomized this response into agree ( strongly agree , agree ) vs. disagree ( mixed , disagree , and strongly disagree ) for sensitivity analyses .
these results were similar to the primary analyses , and we present the results of models with this item entered as a continuous variable .
this is a measure of frailty based upon the  accumulation of deficits  model of frailty , which has good construct validity and predicts a variety of adverse outcomes .
it categorizes individuals as : 
 not frail  walk without help , perform basic activities of daily living , continent of bowel and bladder , and are not cognitively impaired.incontinencebladder incontinence only.mildone ( two if incontinent ) or more of needing assistance with mobility ; or activities of daily living , or has cind , or has bowel or bladder incontinence.moderate/severetwo ( three if incontinent ) or more of totally dependent for transfers or one or more activities of daily life , incontinent of bowel and bladder , or diagnosis of dementia .
not frail  walk without help , perform basic activities of daily living , continent of bowel and bladder , and are not cognitively impaired .
one ( two if incontinent ) or more of needing assistance with mobility ; or activities of daily living , or has cind , or has bowel or bladder incontinence
. moderate / severe  two ( three if incontinent ) or more of totally dependent for transfers or one or more activities of daily life , incontinent of bowel and bladder , or diagnosis of dementia . as a sensitivity analysis , we also considered the frailty index .
forty deficits in multiple domains were considered , and each was considered as present or absent .
the number of deficits was summed and divided by the number of possible deficits to yield a score from 0 to 1 .
we considered this score as a continuous variable and as a dichotomous variable , using a cut - point of 0.25 .
the frailty index and the brief frailty measure were correlated ( spearman s correlation coefficient 0.42 , p < .001 ) .
we also conducted a sensitivity analysis using disability as our outcome . here , we considered the oars at time 1 and time 2 as our outcome .
for these analyses , we summed the oars items from 0 to 28 at both times .
we considered the statement  when you reach my age , you have to accept a fair degree of discomfort and physical disability  as the predictor variable of interest .
categorical variables were compared using chi - square tests and continuous variables were compared using t - tests ( assuming unequal variance ) or one - way analysis of variance ( anova ) .
logistic regression models were constructed , with the outcome of mild / moderate to severe frailty vs. no frailty / incontinence at time 1 . as well , logistic regression models were constructed for the outcome of mild / moderate to severe frailty vs. no frailty / incontinence at time 2 .
continuous variables were entered directly into the model , and categorical variables entered as categories .
bivariate analyses and graphs were conducted in spss version 10 , and statistical models were constructed using stata version 10 ( college station texas ) .
we conducted a secondary analysis of the manitoba study of health and aging ( msha ) , a population - based study conducted in the canadian province of manitoba , done in conjunction with the canadian study of health and aging ( csha ) .
the original aims of this study were to determine the prevalence and risk factors for dementia in manitoba , and to examine social correlates of aging . in 1991/1992 ,
the original sampling frame was from a list provided by manitoba health , the provincial ministry of health .
since health - care coverage is universal in manitoba , this represents a comprehensive representative sampling frame .
older age groups ( over 85 ) were over - sampled , and sampling was stratified by region , with representation from the entire province .
persons residing in institutions ( nursing homes and chronic care hospitals ) did not undergo the screening interview and were not included in these analyses .
initially , 2,890 persons were selected . of these , 443 refused to participate , 480 were not eligible ( had died , had entered a nursing home , or were too ill ) , 162 could not be located , and 54 did not complete the screening questionnaire .
the final sample at time 1 was 1,751 . at time 1 , 1,735 had no missing variables for health beliefs .
the follow - up sample included those who had survived to 1996/7 , who underwent the screening questionnaire with complete data at time 2 , who were living in the community , and who agreed to participate in the study ( n = 1,028 ) . those who were living in institutions at time 2 were excluded since they did not undergo the screening questionnaire . in manitoba ,
nursing homes are not used for convalescence , and those in institutions are very frail . for the prospective analyses , we excluded those who were frail at time 1 , leaving a final sample of 851 .
there were too few participants with mild / moderate frailty who survived and were living in the community to determine if attitudes to disability and aging predicted becoming more frail .
the research was approved by the research ethics committee of the faculty of medicine of the university of manitoba , and adhered to the declaration of helskinki .
data gathered were : age , gender , educational level ( years of education ) , and marital status .
income security was measured with the item :  how do you think your income and assets satisfy your needs ?  and was scored as :  very well / adequately / with some difficulty / not very well / totally inadequately .  we considered this as a continuous measure .
since it was not normally distributed and some cells contained few observations , we also considered it as a dichotomous variable in sensitivity analyses .
these results were similar , and we present the models with this variable included as a continuous factor .
the modified mini - mental state examination ( 3ms ) was used as the screening test for cognitive impairment and dementia .
those who scored less than 78 on the 3ms were invited to participate in a clinical examination to determine the presence of cognitive impairment or dementia .
those with cognitive impairment not meeting these criteria were diagnosed with cognitive impairment no dementia ( cind ) .
this is a heterogeneous group of people with different conditions and circumstances interfering with cognition .
participants were asked about their ability to perform basic activities of daily living ( adl ; eating , dressing , grooming , getting in and out of bed , taking a bath or shower , and ability to use the bathroom ) , instrumental activities of daily living ( iadl ; using the telephone , getting to places out of walking distance , going shopping , preparing meals , doing housework , taking medication[s ] , managing money ) , and ambulation .
the item :  when you reach my age , you have to accept a fair degree of discomfort and physical disability  was asked and scored on a five - point scale .
since there were few people who answered  mixed  and the data were not normally distributed , we also dichotomized this response into agree ( strongly agree , agree ) vs. disagree ( mixed , disagree , and strongly disagree ) for sensitivity analyses .
these results were similar to the primary analyses , and we present the results of models with this item entered as a continuous variable .
this is a measure of frailty based upon the  accumulation of deficits  model of frailty , which has good construct validity and predicts a variety of adverse outcomes .
it categorizes individuals as : 
 not frail  walk without help , perform basic activities of daily living , continent of bowel and bladder , and are not cognitively impaired.incontinencebladder incontinence only.mildone ( two if incontinent ) or more of needing assistance with mobility ; or activities of daily living , or has cind , or has bowel or bladder incontinence.moderate/severetwo ( three if incontinent ) or more of totally dependent for transfers or one or more activities of daily life , incontinent of bowel and bladder , or diagnosis of dementia .
not frail  walk without help , perform basic activities of daily living , continent of bowel and bladder , and are not cognitively impaired .
one ( two if incontinent ) or more of needing assistance with mobility ; or activities of daily living , or has cind , or has bowel or bladder incontinence . moderate / severe  two ( three if incontinent ) or more of totally dependent for transfers or one or more activities of daily life , incontinent of bowel and bladder , or diagnosis of dementia . as a sensitivity analysis
forty deficits in multiple domains were considered , and each was considered as present or absent . the number of deficits was summed and divided by the number of possible deficits to yield a score from 0 to 1 .
we considered this score as a continuous variable and as a dichotomous variable , using a cut - point of 0.25 .
the frailty index and the brief frailty measure were correlated ( spearman s correlation coefficient 0.42 , p < .001 ) .
we also conducted a sensitivity analysis using disability as our outcome . here , we considered the oars at time 1 and time 2 as our outcome .
for these analyses , we summed the oars items from 0 to 28 at both times .
we considered the statement  when you reach my age , you have to accept a fair degree of discomfort and physical disability  as the predictor variable of interest .
categorical variables were compared using chi - square tests and continuous variables were compared using t - tests ( assuming unequal variance ) or one - way analysis of variance ( anova ) .
logistic regression models were constructed , with the outcome of mild / moderate to severe frailty vs. no frailty / incontinence at time 1 . as well , logistic regression models were constructed for the outcome of mild / moderate to severe frailty vs. no frailty / incontinence at time 2 .
continuous variables were entered directly into the model , and categorical variables entered as categories .
bivariate analyses and graphs were conducted in spss version 10 , and statistical models were constructed using stata version 10 ( college station texas ) .
the baseline characteristics of the cross - sectional sample and the prospective sample are shown in table 1 .
those who agreed with the statement ( 80.4% of the time 1 sample ) ,  when you reach my age , you have to accept a fair degree of discomfort and physical disability  , were older , more likely to be women , and had lower levels of education .
there was no difference in mortality or institutionalization over the five - year period between those who agreed or disagreed with the statement ( table 1 ) .
there was a strong and graded association between accepting disability and frailty in the cross - sectional analyses ( figure 1 ) .
the proportion of those who were frail was : 4.8% ( strongly disagree ) ; 12.2% ( disagree ) ; 22.4% ( undecided ) ; 23.4% ( agree ) ; 30.9% ( strongly agree ) ( p < .001 , chi - square test ) .
older age , lower education , less adequate income , and never having married were also associated with frailty .
we sought potential interactions in these associations by entering interaction terms between predictor variables and did not detect any interactions .
however , the numbers for some factors ( e.g. , marital status ) may have been insufficient to detect interactions .
association between accepting disability as a part of aging and frailty in cross - sectional analysis of participants at time 1 results of logistic regression models for time 1 associations ; the odds ratio ( or ) and 95% confidence interval ( ci ) are shown for various models adjusting for potential confounding factors accepting disability is agreeing with the statement that disability is due to aging , scored on a five point scale .
the prospective analysis included those who were not frail at time 1 , and who were alive and available for follow - up at time 2 ( n = 851 ) . accepting disability as part of aging also predicted becoming frail in those who were not frail at time 1 ( figure 2 ) .
the proportion of those who were frail at time 2 was 8.3% ( strongly disagree ) ; 9.8% ( disagree ) ; 18.8% ( undecided ) ; 19.8% ( agree ) ; 30.2% ( strongly agree ) ( p = .007 , chi - square test ) .
this association was also seen in logistic regression models adjusting for potential confounding factors ( table 3 ) .
analyses using the frailty index were similar . accepting disability as a part of aging predicted frailty at time 2 in those who were not frail at time 1 results of logistic regression for the risk of being frail at time 2 ; analyses include those who were not frail at time 1 and had data available at both times ( followed over five years ) , and the odds ratio ( or ) and 95% confidence interval ( ci ) are shown for various models adjusting for potential confounding factors accepting disability is agreeing with the statement that disability is due to aging , scored on a five point scale .
the analyses considering disability as an outcome were very similar . attributing disability as a result of growing old was associated with more disability on the oars at both time 1 and five years later ( figure 3 ) .
this association , between accepting disability as part of aging and disability at both time 1 and time 2 , persisted in multivariable models adjusting for age , gender , and education ( data available upon request ) . accepting disability as a part of aging
is associated with higher levels of disability at time 1 and time 2 we also sought interactions in the effects .
we did not find any interactions in these associations , and the effect was seen in men and women , and in all educational and age groups .
we have found that the belief that disability is due to aging is associated with frailty and , indeed , predicts frailty over a long time interval .
williamson and fried have found that believing disability is a part of aging is strongly associated with disability .
have also found that those who were disabled were more likely to report that their disability is due to aging .
we go on to show this association in men and women in a general , representative population .
previous studies have used a question specific to the person ( i.e. ,  what caused your disability ?  , rather than 
what causes disability ?  ) the question asked in our study would be easier to generalize to a wide population in other settings , as well as being easier to interpret .
as well , our study included a large number of older men , and we found that the association between attitudes to disability and frailty was present in both men and women .
the participants in the msha were less well - educated than some other study populations , and the data are somewhat older .
there may be cohort effects in these beliefs with younger birth cohorts having a different sense of control or different attitudes to aging .
the measure we used may simply be very specific to the risk of frailty and/or disability .
another explanation is that other factors may play a larger role in predicting death and nursing home admission .
first , the original study was conducted in the 1990s and health beliefs may have changed in the intervening time .
it is less likely that the association between health beliefs and frailty has changed in these years , however .
a second limitation is the simplicity of the measure . only a single item was considered in these analyses .
third , we have used a measure of frailty which is consistent with the  frailty as an accumulation of deficits model  used in the csha . the definition we used also weights disability very highly .
indeed , we may simply be measuring the association between attitudes to disability and disability itself .
other alternative models , such as the  frailty as a phenotype  model , may have yielded different results .
the causal nature of the association is thus less clear , and longitudinal associations over long periods of time are needed .
a final limitation is that there may be factors which we have not considered , which may confound or interact with attitudes to health and disability .
previous studies in this area have been conducted primarily in women . while there were gender differences in the belief that disability was due to aging ,
this lack of an association may be due to the definition of frailty we used , which weighted cognition heavily .
a final explanation may be that the effect of gender is mediated through health beliefs and attitudes .
another strength is that reliable , valid measures of disability were used , and were gathered by trained interviewers in person .
first , clinicians should be aware that older adults who view disability as a part of aging may be at higher risk for frailty .
second , it is possible that interventions to increase the sense of control over health may be useful in reducing the risk of frailty . addressing depressive symptoms , social isolation , and other factors may increase a sense of control . since the belief that disability is due to aging is widespread , the potential intervention could benefit a large number of people . further research into the causal relationship between this association is of course needed prior to any intervention study .
future research would need to focus on the stability of these beliefs over time , and how they change with changing disability and frailty .
 backgroundthe objectives are to determine if : 1 ) accepting disability as a part of aging is associated with frailty ; and 2 ) accepting disability is associated with becoming frail over a five - year period.methodssecondary analysis of a prospective cohort study of 1,751 community - dwelling adults aged 65 + . 
 participants were asked to rate their agreement with the statement :  when you reach my age , you have to accept a fair degree of discomfort and physical disability  on a five - point scale . 
 frailty was categorized as not frail or frail . 
 the sample was re - interviewed five years later.resultsthe mean age was 75.5 years , 62.3% were women , and the mean education was 10.2 years . accepting disability as a part of aging 
 was strongly associated with frailty at time 1 ; the unadjusted odds ratio ( or ) and 95% confidence interval ( ci ) was 1.47 ( 1.25 , 1.72 ) and this association persisted after adjusting for confounding factors . 
 accepting disability was also associated with becoming frail ; the unadjusted or and 95% ci was 1.51 ( 1.20 , 1.90 ) , and this association also persisted after adjusting for potential confounding factors.conclusionsaccepting disability as a part of aging is associated with being frail and becoming frail . 
INTRODUCTION
METHODS
Population
Measures
Analyses
RESULTS
DISCUSSION
CONCLUSION
CONFLICT OF INTEREST DISCLOSURES