Journal of Clinical Medicine Article Profiles of Frailty among Older People Users of a Home-Based Primary Care Service in an Urban Area of Barcelona (Spain): An Observational Study and Cluster Analysis Juan-José Zamora-Sánchez 1,2, * , Edurne Zabaleta-del-Olmo 1,3,4,5 , Sergio Fernández-Bertolín 3,4 , Vicente Gea-Caballero 6,7 , Iván Julián-Rochina 8 , Gemma Pérez-Tortajada 9 and Jordi Amblàs-Novellas 10 1 Atenció Primària Barcelona Ciutat, Gerència Territorial de Barcelona, Institut Català de la Salut, 08007 Barcelona, Spain; ezabaleta@idiapjgol.org 2 School of Nursing, Universitat de Barcelona, 08036 Barcelona, Spain 3 Fundació Institut Universitari per a la Recerca a l’Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), 08007 Barcelona, Spain; sfernandez@idiapjgol.org 4 Universitat Autònoma de Barcelona, 08193 Bellaterra (Cerdanyola del Vallès), Spain 5 Nursing Department, Faculty of Nursing, Universitat de Girona, 17004 Girona, Spain 6 Escuela de Enfermería La Fe, 46026 Valencia, Spain; gea_vic@gva.es 7 Grupo de investigación GREIACC, Instituto de Investigación Sanitaria La Fe, 46026 Valencia, Spain 8 Department of Nursing, Faculty of Nursing and Podiatry, Universitat de València, 46010 Valencia, Spain; ivan.julian@uv.es 9 Atenció Primària de l’Àrea Metropolitana Nord, Gerència Territorial Metropolitana Nord, Institut Català de la   Salut, 08916 Barcelona, Spain; gperezto.mn.ics@gencat.cat 10 Central Catalonia Chronicity Research Group (C3RG), Centre for Health and Social Care Research (CESS), Citation: Zamora-Sánchez, J.-J.; Universitat de Vic-University of Vic-Central University of Catalonia (UVIC-UCC), 08500 Vic, Spain; Zabaleta-del-Olmo, E.; jamblas@chv.cat Fernández-Bertolín, S.; Gea-Caballero, * Correspondence: jjzamora.bcn.ics@gencat.cat V.; Julián-Rochina, I.; Pérez-Tortajada, G.; Amblàs-Novellas, J. Profiles of Abstract: Background: The multidimensional assessment of frailty allows stratifying it into degrees; Frailty among Older People Users of however, there is still heterogeneity in the characteristics of people in each stratum. The aim of this a Home-Based Primary Care Service study was to identify frailty profiles of older people users of a home-based primary care service. in an Urban Area of Barcelona (Spain): An Observational Study and Cluster Methods: We carried out an observational study from January 2018 to January 2021. Participants were Analysis. J. Clin. Med. 2021, 10, 2106. all people cared for a home-based primary care service. We performed a cluster analysis by applying a https://doi.org/10.3390/jcm10102106 k-means clustering technique. Cluster labeling was determined with the 22 variables of the Frail-VIG index, age, and sex. We computed multiple indexes to assess the optimal number of clusters, and this Academic Editor: Hiroyuki Shimada was selected based on a clinical assessment of the best options. Results: Four hundred and twelve participants were clustered into six profiles. Three of these profiles corresponded to a moderate frailty Received: 29 March 2021 degree, two to a severe frailty degree and one to a mild frailty degree. In addition, almost 75% of the Accepted: 7 May 2021 participants were clustered into three profiles which corresponded to mild and moderate degree of Published: 13 May 2021 frailty. Conclusions: Different profiles were found within the same degree of frailty. Knowledge of these profiles can be useful in developing strategies tailored to these differentiated care needs. Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in Keywords: care dependence; cluster analysis; frailty; home care; multimorbidity; primary health care published maps and institutional affil- iations. 1. Introduction The aging of the world’s population is contributing to an increase in the number of Copyright: © 2021 by the authors. people with multimorbidity and complex care needs; as a result, the condition of frailty Licensee MDPI, Basel, Switzerland. is receiving greater international interest [1]. Frailty is characterized by a decline in the This article is an open access article distributed under the terms and functioning of multiple physiological systems accompanied by an increased vulnerability conditions of the Creative Commons to stressors [2]. Moreover, frailty determines a reduction in functional reserve and a higher Attribution (CC BY) license (https:// risk of adverse outcomes such as increased mortality, disability and use of healthcare creativecommons.org/licenses/by/ resources [3–5]. It is also age-related, progressive, dynamic and potentially modifiable–and, 4.0/). therefore, preventable [6,7]. Furthermore, the introduction of the concept of frailty in J. Clin. Med. 2021, 10, 2106. https://doi.org/10.3390/jcm10102106 https://www.mdpi.com/journal/jcm J. Clin. Med. 2021, 10, 2106 2 of 12 clinical practice allows the identification of complex care needs by differentiating between chronological and biological age. Today, the definition of frailty remains questioned, but according to the World Health Organisation, it is defined as “a progressive age-related decline in physiological systems that results in decreased reserves of intrinsic capacity, which confers extreme vulnerability to stressors and increases the risk of a range of adverse health outcomes” [8]. The main measurement approaches are the Fried’s frailty phenotype [9] and Rockwood and Mitnit- ski’s accumulation of deficits model [10]. The frailty phenotype is based on the presence of three or more of the following criteria: involuntary weight loss, exhaustion, slow gait speed, poor handgrip strength, and sedentary behaviour. Its use may be more suitable for the identification of non-disabled older people at risk of adverse health outcomes [11]. Regarding the accumulation of deficits model, allows an understanding of the concept through the complex interaction of physical, psychological and social factors that lead to frailty, expressed as a frailty index (FI). This FI is a ratio of potential age-related deficits that include disease, disability and geriatric syndromes [10]. The FI may be a more useful tool than the frailty phenotype to establish the effectiveness of any intervention and to describe the health status trajectories over time [11,12]. A large number of FIs have been developed based on this model, among which we highlight the Frail-VIG index. It has a multidimensional approach and is based on a comprehensive geriatric assessment (VIG is the Spanish/Catalan abbreviation for ‘comprehensive geriatric assessment). The Frail-VIG index fits well with the biopsychosocial model of primary care and allows stratification of people into degrees of frailty, making it easier to set tailored therapeutic goals and therapeutic intensity [13]. However, we still found heterogeneity among the characteristics of the people classi- fied under each degree of frailty. Therefore, identifying different profiles of people would contribute to gaining additional knowledge about specific characteristics, and consequently, further facilitate personalization of the care plan. A number of previous studies have ex- plored this approach with a comprehensive assessment approach among older people living in the community. Lafortune et al. identify four profiles, incorporating the physical and cognitive dimensions [14]. Armstrong et al. identify seven relatively homogeneous profiles among people receiving rehabilitation at home, which differ in terms of character- istics such as age, sex, cognition and functional impairment [15]. In a more recent study, Looman et al. identify six clusters around physical, cognitive and social functioning [16]. Other authors explore patterns based on multimorbidity [17,18], which is defined as the presence of two of more chronic diseases or conditions [19]. However, profiles based solely on morbidity do not capture other aspects of people’s complex needs when considering at-home care. In this regard, multidimensional FIs include interrelated concepts of interest such as morbidity, frailty and dependence. On the other hand, morbidity can be considered as an antecedent of frailty and dependence as a consequence of it [20,21]. Dependence is defined as a person’s lack of ability to perform basic activities needed for daily living as a result of a decrease in functional capacity [8]. It is important to identify these concepts correctly [22], because whilst they are related, their management is different and can confuse interventions designed to prevent and mitigate frailty. In addition, no research has been found that analyzed people’s profiles from a broad perspective, incorporating different domains of frailty (biological, psychological, and social), together with multimorbidity and dependence. Finally, people living with frailty risk experiencing a decline in their quality of life. Previous research shows the negative association between frailty, multimorbidity and dependence with respect to quality of life [23–25] Therefore, interventions aimed at decreasing frailty could have the added benefit of improving quality of life. For all these reasons we decided to carry out this study, the aim of which was to identify frailty profiles of older people users of a home-based primary care service, from a comprehensive perspective, using the Frail-VIG index which integrates the concepts of frailty (physical, cognitive and social), multimorbidity and dependence. J. Clin. Med. 2021, 10, 2106 3 of 12 2. Materials and Methods 2.1. Study Design, Scope, Period and Subjects We carried out an observational study and cluster analysis in two health care areas of the Institut Català de la Salut (Catalan Health Institute) in Barcelona, Spain, that serve a population of 51,121 users. This is a population with a medium-high socioeconomic level and a lower percentage of immigration than the mean for Catalonia (9.8% and 8.8% respectively, compared to 14.6% for Catalonia) and a high level of over-aging (26.8% and 28.8% of people over 65 respectively, compared to the Catalan mean of 19.4%) [26]. The study period was from January 2018 to January 2021. Participants were all people included to under the home-care program during 2018. This program included all those who could not go to the health center for reasons of health, physical condition, or their social situation or environment. Two general practi- tioners and four community nurses manage this program, which was also supported by a social worker and a nurse case manager. All variables were assessed at baseline, except mortality, which was evaluated at 12 and 24 months after baseline. 2.2. Measurement Variables and Instruments Frailty was measured using the Frail-VIG index. Published in 2017 by Amblàs- Novel- las et al. [27], this FI based on the comprehensive geriatric assessment, consists of 22 trigger questions that are used to assess 25 deficits from eight assessment domains (functional, nutritional, cognitive, emotional, social, geriatric syndromes, severe symptoms and chronic diseases). The final score, which is obtained by dividing the accumulated deficits by the total potential accumulable deficits, range from 0 to 1 (with the submaximal limit in the clinical practice being close to 0.7). There is an Excel calculator available at: https://en.c3rg.com/index-fragil-vig (accessed on 11 May 2021). It enables people to be grouped according to degrees of frailty: non-frailty (<0.20), mild frailty (0.20–0.35), moderate frailty (0.36–0.50) and severe frailty (>0.50). The Frail-VIG index has shown a high prognostic value for 12-month mortality (value under the ROC curve of 0.9, 95% CI 0.88–0.92) [13,27]. For the cluster analysis, the variables were grouped as: sociodemographic (age, sex), diseases (cardiac, respiratory, renal, neurological, hepatic/digestive, cancer), symptoms (pain, dyspnoea), physical frailty (nutrition, falls, ulcers, dysphagia), psychological frailty (delirium, cognitive impairment, depression, anxiety), social vulnerability (the person lives alone or the family has limitations or difficulty in offering support, conflictive family relationship, inadequate hygiene conditions, inadequate housing, and lack of economic resources), and functional dependence for activities of daily living (ADLs) and instrumental activities of daily living (IADLs) As a covariable, the perception of quality of life was measured by means of the EQ-5D- 3L index, using the reference values for the Spanish population [28]. We also determined whether or not all participants had died at 12 and 24 months after the baseline assessment date, by reviewing primary care electronic health records, which systematically include the date of death. 2.3. Data Collection and Sources of Information Community nurses from the home-care service performed a comprehensive geriatric assessment as part of their usual practice. They also administered by interview the two measurement instruments: the Frail-VIG index and the EQ-5D-3L index. The research team held a preliminary consensus meeting with these nurses to unify criteria for collecting the data from the aforementioned instruments, and a pilot test was carried out with 20 participants to identify potential problems and introduce strategies for improvement. After the pilot, no changes in the procedure were necessary, and an instruction manual was written to ensure homogeneous data collection. J. Clin. Med. 2021, 10, 2106 4 of 12 For the assessment of mortality at 12 and 24 months after the baseline assessment, we reviewed electronic health records, which include up-to-date information on date of death, regardless of the place where the death occurred. 2.4. Study Size No sampling strategy was used in this study. All the older people users of the home-based primary care service were included. In Spain, access to primary care is guaranteed by law and home care is part of the primary care service portfolio [29]. There is a comprehensive, multidisciplinary home care program; the study population was identified from the patient lists for this population-based care program. 2.5. Data Analysis Categorical variables were expressed as frequencies and percentages and continuous variables as mean and standard deviation. Differences between clusters for descriptive variables were evaluated using the chi-square test, ANOVA and Kruskal–Wallis based on application conditions. The cluster analysis was performed by applying the k-means hard clustering technique to the dataset. Prior to the clustering, a manual selection of variables was done to avoid overestimation of some data, and only the 22 variables of the frailty index, age and sex were used to determine the cluster labeling. The criterion for selecting these variables was to avoid duplicity of variables with similar clinical meaning. After grouping the individuals into different clusters with these features, all variables were used to characterize the clusters. PCAmix compression technique was used to reduce dimensionality of the data, noise and deal efficiently with both dichotomous and continuous variables. Using this technique, principal component analysis (PCA) was applied to the continuous age variable and multiple correspondence analysis (MCA) to the dichotomous variables. According to Kaiser criterion, only the most significant 13 transformed dimensions were retained to feed the k-means clustering. To assess the optimal number of clusters (k), Calinski-Harabasz, Xie-Beni and Silhou- ette indexes were computed from the average of 100 different realizations for each possible number from two to 20 [30]. To mitigate the negative effects of the random nature of the clustering, a clusterboot technique was used to select the most stable cluster from 100 dif- ferent realizations. The Calinski index did not reveal clear evidence for any clusters, while Xie-beni and Silhouette gave better results for groups of three, six and nine clusters. Finally, the determination of the optimal number of clusters was defined based on the principle of parsimony and the potential clinical value of these three best options mentioned above. A cluster was considered clinically valuable when it facilitated more tailored care (targeted interventions) for frail people. R version 3.6.3 software (Vienna, Austria) was used to preprocess the data and to apply the clustering and IBM SPSS Statistic version 24 (Armonk, NY, USA) to characterize the different obtained profiles. 2.6. Ethical Aspects Informed consent was requested from the participants after they had been given oral and written information about the aims of the study. The study complies with Spanish regulations regarding the protection of personal data and was approved by the IDIAP’s Clinical Research Ethics Committee–registration number P17/150. 3. Results A total of 412 people participated in the study, mostly women (68.4%), with a mean age of 88 (SD 8.1). Table 1 shows the characteristics of the participants in the total population. 31.3% of cases had three or more target organ diseases–the most prevalent being heart disease (60.2%) and chronic kidney failure (50.0%). More than 60% of participants reported significant functional dependence for ADLs and IADLs. Approximately half had some J. Clin. Med. 2021, 10, 2106 5 of 12 cognitive impairment, 51.5% showed social vulnerability and 17.0% lived alone. Quality of life was negatively correlated with the degree of frailty. We described this finding in more detail in a recent publication [31]. Overall mortality of the population at one year was 31.1% and 46.1% at two years, with significant differences between the six profiles identified (Table 1). Table 1. Characteristics of participants in each of the six profiles identified through cluster analysis. Values are absolute frequencies (percentages) unless stated otherwise. Total Profile 1 Profile 2 Profile 3 Profile 4 Profile 5 Profile 6 p-Value Variables n = 412 n = 106 n=4 n = 101 n = 92 n = 65 n = 44 (*) Age Years, mean (SD) 88.0 (8.1) 87.7 (0.7) 83.8 (6.8) 86.1 (0.8) 92.7 (0.6) 87.9 (0.9) 84.4 (1.7) <0.001 Men 130 (31.6) 25 (23.6) 2 (50.0) 44 (43.6) 14 (15.2) 35 (53.8) 10 (22.7) Sex Women 282 (68.4) 81 (76.4) 2 (50.0) 57 (56.4) 78 (84.8) 30 (46.2) 34 (77.3) <0.001 Cancer (active) 40 (9.7) 4 (3.8) 4 (100.0) 10 (9.9) 9 (9.8) 12 (18.5) 1 (2.3) 0.009 Respiratory 116 (28.2) 29 (27.4) 3 (75.0) 48 (47.5) 7 (7.6) 20 (30.8) 9 (20.5) <0.001 Cardiac 248 (60.2) 59 (55.7) 0 (0.0) 85 (84.2) 37 (40.2) 51 (78.5) 16 (36.4) <0.001 Neurological 151 (36.7) 17 (16.0) 1 (25.0) 48 (47.5) 22 (23.9) 40 (61.5) 23 (52.3) <0.001 Chronic Diseases Digestive 39 (9.5) 16 (15.1) 0 (0) 7 (6.9) 6 (6.5) 6 (9.2) 4 (9.1) 0.234 Renal (GFR < 60) 206 (50.0) 56 (52.8) 1 (25.0) 56 (55.4) 57 (62.0) 28 (43.1) 8 (18.2) <0.001 ≥3 target organ diseases 129 (31.3) 30 (28.3) 1 (25.0) 51 (50.5) 15 (16.3) 30 (46.2) 2 (4.5) <0.001 Advanced Chronic 32 (7.8) 3 (2.8) 4 (100) 18 (17.8) 1 (1.1) 5 (7.7) 1 (2.3) <0.001 Disease Pain 87 (21.1) 26 (24.5) 1 (25.0) 34 (33.7) 20 (21.7) 6 (9.2) 0 (0.0) <0.001 Severe Symptoms Dyspnea 19 (4.6) 4 (3.8) 0 (0.0) 14 (13.9) 0 (0.0) 0 (0.0) 1 (2.3) NA Delirium 119 (28.9) 4 (3.8) 1 (25.0) 6 (5.9) 43 (46.7) 37 (56.9) 28 (63.6) <0.001 Falls 112 (27.2) 27 (25.5) 1 (25.0) 21 (20.8) 33 (35.9) 24 (36.9) 6 (13.6) 0.012 Ulcers 85 (20.6) 10 (9.4) 2 (50.0) 13 (12.9) 21 (22.8) 24 (36.9) 15 (34.1) <0.001 Geriatric syndromes Dysphagia 75 (18.2) 0 (0.0) 1 (25.0) 11 (10.9) 1 (1.1) 29 (44.6) 33 (75.0) <0.001 Incontinence 295 (71.6) 45 (42.5) 4 (100) 70 (69.3) 79 (85.9) 54 (83.1) 43 (97.7) <0.001 Polypharmacy (≥5 drugs) 365 (88.6) 92 (86.8) 4 (100.0) 100 (99.0) 74 (80.4) 60 (92.3) 35 (79.5) <0.001 ≥3 geriatric syndromes 87 (21.1) 3 (2.8) 1 (25.0) 6 (5.9) 20 (21.7) 33 (50.8) 24 (54.5) <0.001 Weight loss Malnutrition 70 (17.0) 18 (17.0) 2 (50.0) 11 (10.9) 10 (10.9) 22 (33.8) 7 (15.9) 0.001 ≥5% in the last 6 months Cognitive impairment 214 (51.9) 13 (12.3) 1 (25.0) 24 (23.8) 77 (83.7) 58 (89.2) 41 (93.2) <0.001 Cognitive impairment Pfeiffer (Range 0–10), 3.76 (3.33) 1.15 (0.15) 2.75 (1.80) 1.94 (0.20) 4.93 (0.23) 5.84 (0.36) 8.86 (0.39) <0.001 mean (SD) Treatment for depression 158 (38.3) 34 (32.1) 2 (50.0) 48 (47.5) 35 (38.0) 20 (30.8) 19 (43.2) 0.117 Emotional Status Treatment for 226 (54.9) 53 (50.0) 1 (25.0) 74 (73.3) 45 (48.9) 25 (38.5) 28 (63.6) <0.001 anxiety/insomnia Presence of social 212 (51.5) 83 (78.3) 1 (25.0) 44 (43.6) 36 (39.1) 35 (53.8) 13 (29.5) <0.001 vulnerability Social Vulnerability Living alone 70 (17.0) 43 (40.6) 0 (0.0) 15 (14.9) 6 (6.5) 5 (7.7) 1 (2.3) <0.001 Professional caregiver 97 (23.5) 11 (10.4) 0 (0.0) 27 (26.7) 27 (29.3) 18 (27.7) 14 (31.8) 0.005 24 h a day Barthel Index, mean (SD) 48.4 (26.9) 73.0 (1.4) 35.0 (5.4) 51.1(1.7) 51.4 (1.8) 28.2 (3.3) 7.9 (2.1) <0.001 BI ≥ 95 No dependency 6 (1.5) 4 (3.8) 0 (0.0) 0 (0.0) 1 (1.1) 1 (1.5) 0 (0.0) Basic Activities of BI 90–65 (Mild–moderate) 143 (34.7) 85 (80.2) 0 (0.0) 26 (25.7) 22 (23.9) 9 (13.8) 1 (2.3) Daily Living <0.001 (**) BI 60–25 Barthel Index (BI) 175 (42.5) 16 (15.1) 4 (100.0) 71 (70.3) 67 (72.8) 15 (23.1) 2 (4.5) (Moderate–severe) BI ≤ 20 Absolute 88 (21.4) 1 (0.9) 0 (0.0) 4 (4.0) 2 (2.2) 40 (61.5) 41 (93.2) dependency Instrumental Activities of Money management 350 (85.0) 50 (47.2) 3 (75.0) 97 (96.0) 91 (98.9) 65 (100.0) 44 (100.0) <0.001 Daily Living Telephone use 132 (32.0) 0 (0.0) 0 (0.0) 10 (9.9) 26 (28.3) 52 (80.0) 44 (100.0) <0.001 (needs help) Medication management 304 (73.8) 19 (17.9) 2 (50.0) 85 (84.2) 89 (96.7) 65 (100.0) 44 (100.0) <0.001 Frail VIG index, mean 0.40 (0.12) 0.28 (0.01) 0.44 (0.02) 0.41 (0.01) 0.39 (0.01) 0.52 (0.01) 0.53 (0.01) <0.001 (SD) Frailty Frail-VIG Non frailty (FI <0.20) 12 (2.9) 12 (11.3) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) index (FI) Range 0–1 Mild frailty (FI 0.20–0.35) 116 (28.2) 68 (64.2) 0 (0.0) 23 (22.8) 24 (26.1) 1 (1.5) 0 (0.0) <0.001 Moderate frailty (***) 191 (46.4) 26 (24.5) 4 (100) 63 (62.4) 58 (63.0) 28 (43.1) 12 (27.3) (FI 0.36–0.50) Severe frailty (FI >0.50) 93 (22.6) 0 (0.0) 0 (0.0) 15 (14.9) 10 (10.9) 36 (55.4) 32 (72.7) EQ-5D-3L Index. Quality of life (Range 0–1) 0.30 (0.23) 0.44 (0.18) 0.29 (0.16) 0.29 (0.21) 0.31 (0.24) 0.19 (0.24) 0.08 (0.01) <0.001 mean (SD) Mortality of 12 months 128 (31.1) 14 (13.2) 4 (100.0) 30 (29.7) 27 (29.3) 34 (52.3) 19 (43.2) <0.001 Mortality Mortality of 24 months 190 (46.1) 31 (29.2) 4 (100.0) 44 (43.6) 40 (43.5) 45 (69.2) 26 (59.1) <0.001 (*) Profile 2 (4 cases) has been excluded in all p-value analyzes, in order to adjust to the application requirements of the tests. (**) The values of the Barthel index have been grouped into three levels (BI ≥ 95; BI 90–25; BI ≤ 20), to adapt the criteria for applying the chi-square test. (***) The frail-VIG index values have been grouped into three degrees of frailty (FI ≤ 0.35; FI 0.36–0.50; FI > 0.50) to adapt the criteria for applying the chi-square test. NA. The p-value calculation requirements do not apply. Abbreviations: BI, Barthel Index; FI, Frail-VIG Index; GFR, Glomerular Filtration Rate; SD, Standard Deviation. Mortality MortalityMortality of Mortality Mortality 12 12 of months Mortalityof12 of of 12 months 12of months months months 12 128128 months (31.1) 128 128 128 (31.1) 14(31.1) (31.1) (31.1) 128 (13.2) 14 (13.2) (31.1) 14 14 14(13.2)4(13.2) (13.2) 14 (100.0) 4(13.2) (100.0)4 (100.0) 430(100.0) 44(100.0) (100.0) (29.7) 30 (29.7)30 30(29.7) 30 27 (29.7) (29.7) 30 (29.3) 27 (29.3) (29.7) 27 27 34 27(29.3)(29.3) (29.3) 27 (52.3) 34 34 (52.3) (29.3)34(52.3) 34 19 (52.3) (52.3) 34 (43.2) 19 19 (43.2) (52.3)19(43.2) 19 <0.001 (43.2) (43.2) 19 <0.001 (43.2) <0.001 <0.001 <0.001<0.001 Mortality MortalityMortality Mortality Mortality Mortality Mortality MortalityMortality of Mortality Mortality 24 24 of months Mortalityof24 of of 24 months 24of months months months 24 190190 months (46.1) 190 190 190 (46.1) 31(46.1) (46.1) (46.1) 190 (29.2) 31 (29.2) (46.1) 31 31 31(29.2)4(29.2) (29.2) 31 (100.0) 4(29.2) (100.0)4 (100.0) 444(100.0) 44(100.0) (100.0) (43.6) 44 (43.6)44 44(43.6) 44 40 (43.6) (43.6) 44 (43.5) 40 (43.5) (43.6) 40 40 45 40(43.5)(43.5) (43.5) 40 (69.2) 45 45 (69.2) (43.5)45(69.2) 45 26 (69.2) (69.2) 45 (59.1) 26 26 (59.1) (69.2)26(59.1) 26 <0.001 (59.1) (59.1) 26 <0.001 (59.1) <0.001 <0.001 <0.001<0.001 (*)(*) Profile (*) (*) Profile2Profile (*)(4 (*)Profile Profile cases) 2Profile (4 2cases) 22cases) (4(4 (4has cases) 2cases) (4hasbeen has cases) has has beenexcluded been been has been excluded been excluded in excluded excluded allin in excluded p-value all in inall all p-value allin analyzes, p-value p-value p-value all analyzes, analyzes, in analyzes, p-value analyzes, order in analyzes, order in in toin inorderorder adjust order to adjusttoto toadjust order to adjust adjust to the to application the to adjust to to the the application the to application requirements application application the requirements requirements application requirements requirements of oftheof requirements the of ofthe thethe of the tests. (**) tests. tests. tests. The tests. (**) (**) The tests. (**) (**) values The The (**)The values ofvalues values values The the of the values of Barthel of of the the the Barthel of index Barthel Barthel Barthel the index Barthelhave index index indexhave been index have have have been grouped been have been been grouped grouped into grouped been grouped into grouped three into into into threelevels three three three into levels (BIlevels levels three levels ≥levels (BI 95; (BI(BI ≥BI ≥ 95; (BI ≥(BI ≥90–25; BI 95; 95; 95; BI 90–25; BI ≥BI 95; BI90–25; 90–25; 90–25; BI ≤90–25; BI 20), ≤BI ≤BI20), BI ≤to ≤to adapt 20), 20), BI 20), adapttothe toadapt ≤to 20), toadapt adaptthe thethe adapt the the criteria criteriafor criteria criteria criteria applying for forfor applying criteria for applying applying for the applying chi-square the applyingthe the the chi-square chi-square test. chi-square chi-square the (***) test. chi-squaretest. test. test. The (***)(***)(***) (***) The test. frail-VIG The The (***) The frail-VIGfrail-VIG index frail-VIG frail-VIG The index frail-VIG values index index index values have values values index valueshave been have values have have been grouped been have been been grouped grouped grouped been grouped intointo groupedthree intointo three into degrees three three three intodegrees degrees ofdegrees degrees three degrees frailty of of frailty of frailty offrailty frailty of frailty J. Clin. Med. 2021, 10, 2106 6 of 12 (FI(FI ≤ (FI 0.35; (FI(FI ≤ 0.35; FI ≤≤(FI≤ FI ≤0.35; 0.35;0.36–0.50; 0.35; 0.35; FI FI FI0.36–0.50; 0.36–0.50; FI0.36–0.50;FI FI 0.36–0.50; > FI 0.50) 0.36–0.50; >FI >FI0.50) to FI> to >0.50)>0.50) adapt 0.50) adaptto toadapt 0.50) to the toadapt adaptthecriteria adapt thethethe criteria for criteria criteria criteria the forapplying for for applying criteria for forapplying the applying applying thechi-square applying the the thechi-square chi-square the chi-square chi-square test. test. chi-squareNA. test. test. NA. test. The NA. NA. NA. The test. p-value The The NA. The p-value p-value calculation p-value p-value The calculation calculation calculation p-value calculation calculation requirementsrequirements requirements requirements requirements dodo not requirements not dodoapply. donot notdonot apply. Abbreviations: apply. apply. apply. not apply. Abbreviations: Abbreviations: Abbreviations: Abbreviations: BI,BI, Abbreviations: Barthel BI,BI, Barthel BI, Index; Barthel Barthel Barthel BI, Index; BarthelFI, Index;Index; Index; Frail-VIG FI, FI,FI, Frail-VIG Index; FI, Frail-VIG Index; Frail-VIG Frail-VIG FI, Index; Frail-VIG GFR, Index; Index; Index; GFR, Glomerular GFR, GFR, Index; GFR, Glomerular Glomerular Glomerular GFR, Glomerular Filtration Filtration Glomerular Filtration Rate; Filtration Filtration Rate;SD, Rate; Rate; Filtration Rate;SD, SD, Rate; SD, SD,SD, Standard Standard Standard Deviation. Standard Standard Deviation. Deviation. StandardDeviation. Deviation. Deviation. Comparing Comparing Comparing Comparingthethe Comparing three, Comparing the the Comparing the three,six three, three, three, the the and six six and three, six six nine and and three, and nine six cluster nine and six nine nine and groups, cluster cluster cluster nine groups, cluster cluster nine groups, the groups, groups, cluster six-cluster the the groups, the the six-cluster six-cluster group six-cluster six-cluster groups,thethe group was group group six-cluster group six-clusterwas found was group was was found group tofound found found was to toto found was toto found bebe thebemost be be the the thebethe most parsimonious most most most the most parsimonious parsimonious parsimonious parsimonious and parsimoniousandclinically and and and and clinically clinically valuable. clinically clinically clinicallyvaluable. valuable.Tables valuable. valuable. Tables1 Tables and Tables valuable. Tables1 and 1 Tables 1 21 summarize and and 2and 1 2 summarize summarize 22 and summarize summarize to be the most parsimonious and clinically valuable. Tables 1 and 2 summarize the main 2 the main the summarize the the the main main main main the main characteristics characteristics characteristicsof of characteristics characteristics the characteristics of six the of characteristics of the profiles thethe six of six six of thesix profiles profilesidentified, profiles profiles the six six profiles identified, identified, ordered identified, identified, profiles identified,ordered ordered by ordered ordered identified, degree by byby degree ordered by ordered of degree frailty. degree degree by by of of frailty. frailty. degree ofoffrailty. degree frailty. of of frailty. frailty. Table 2. Table Table TableSummary Table 2.Table Table2. Summary Summary 2.2.Summary 2. of Summary thethe of 2.Summary Summaryvariables ofof of the the the of variables variablesused variables variables ofthe the to used define variables usedused used to variables used to to usedeach define define todefine define to to ofeach each the define eacheach of define six the of of eachof frailty the six the each the of ofsix six six the profiles frailty frailty frailty in profiles profiles frailty the six six the profiles frailty in profiles frailty cluster the inin profilesin the the cluster the profiles in analysis. cluster cluster analysis. analysis. cluster in the the analysis. cluster analysis. cluster analysis. analysis. 11 1 11 1 1 2 22 22 2 2 3 3 333 3 3 4 4 444 4 4 5 5 55 55 5 6 6 66 6 66 Profiles Domains (n == 106) (n (n =(n(n 106) (n 106) = ==106)106) 106) (n (n = 4) = 106) (n =(n(n (n = (n = 4)==4)(n 4) 4) (n = 101) 4) = 4) (n =(n(n (n (n 101) = = ==101)101) 101) (n 101) (n = 92) = 101) (n =(n(n (n 92) (n = 92) (n = 65) 92)= 92) (n =(n(n = 92) = (n 92) (n 65) 65)= 65) (n44) = ==65) (n = 65) 65) (n = =(n(n=(n 44) =44)= 44) 44) (n 44) = 44) Profiles Profiles Profiles Profiles Profiles Profiles Domains DomainsDomains Domains Domains Domains Degree ofoffrailty Mild frailty Moderate Moderate Moderate Moderate Moderate ModerateModerate frailty Moderate Moderate Moderate Moderate frailtyModerate Moderate ModerateModerate Moderate Moderate Moderate Moderate Moderate Moderate frailty Severe frailty Severe frailty Degree Degree of DegreeDegree Degree frailty of frailty Degree of of frailty offrailty frailty frailty Mild Mild frailty Mild Mild Mild frailty frailty frailty Mild frailty frailty Severe Severefrailty Severe Severe Severe frailty frailty Severe frailty Severe frailty Severefrailty Severe Severe frailty Severefrailty frailty frailty Severe frailtyfrailty Age (years) 87.7 frailty frailty frailty frailty 83.8 frailtyfrailty frailty frailty frailty frailty 86.1 frailtyfrailty frailty frailty frailty frailty frailty 92.7frailty 87.9 84.4 Age Age Women (years) AgeAge Age (years) (%) (years) (years) (years) Age (years) 76.4 87.787.7 87.7 87.7 87.7 87.7 83.8 5083.8 83.8 83.8 83.8 83.8 86.1 86.156.4 86.1 86.1 86.1 86.1 92.7 92.7 84.8 92.7 92.7 92.7 92.7 87.9 87.9 46.1 87.9 87.9 87.9 87.9 84.4 84.4 84.4 84.4 77.3 84.4 84.4 Chronic diseases WomenWomen and Women Women Women severe(%) (%) Women (%) (%) symptoms (%) (%) 76.4 276.4 76.4 76.4 76.4 76.4 503.6 50 50505050 56.4 56.4 56.4 56.4 3.2 56.4 56.4 84.8 84.8 84.8 84.8 84.8 1.7 84.8 46.1 46.1 46.1 46.1 46.1 46.1 77.3 2.6 77.3 77.3 77.3 77.3 77.3 1.4 Chronic Chronic Chronic Chronic (0–6) Chronic diseases diseases Chronic diseases diseases diseases diseases Physical frailty (0–4) 2 2 22 2 2 3.63.63.63.63.63.6 3.23.23.2 3.23.23.2 1.71.71.7 1.71.71.7 2.62.62.6 2.62.62.6 1.41.41.4 1.41.41.4 andandsevere and and and severe symptoms severe and severe severesymptoms symptoms symptoms severe symptoms (0–6)(0–6) symptoms (0–6) (0–6) (0–6) (0–6) (malnutrition, falls, 0.6 1.6 0.5 0.7 1.5 1.4 hysical PhysicalPhysical frailty Physical Physical frailty Physical (0–4) frailty frailty frailty (0–4) ulcers, (malnutrition, (0–4) frailty (0–4) (0–4) (malnutrition, (malnutrition, dysphagia) (malnutrition, (0–4) (malnutrition, (malnutrition, 0.60.60.60.60.60.6 1.61.61.6 1.61.61.6 0.50.50.5 0.50.50.5 0.70.70.7 0.70.70.7 1.51.51.5 1.51.51.5 1.41.41.4 1.41.41.4 falls, falls, Psychological ulcers,falls, falls, ulcers, falls, dysphagia) ulcers, ulcers, falls, ulcers, dysphagia) frailty dysphagia) dysphagia) ulcers, dysphagia) dysphagia) (0–5) PsychologicalPsychological Psychological Psychological Psychological frailty frailty Psychological (delirium, cognitive (0–5) frailtyfrailty frailty(0–5) frailty (0–5)(0–5) (0–5) (0–5) 0.9 1.6 1.5 2.3 2.2 3.4 (delirium, (delirium, (delirium, cognitive (delirium, (delirium, cognitive (delirium, cognitive impairment, cognitive cognitive impairment, impairment, cognitive impairment, impairment, impairment, depression, impairment, 0.90.90.90.90.90.9 1.61.61.6 1.61.61.6 1.51.51.5 1.51.51.5 2.32.32.3 2.32.32.3 2.22.22.2 2.22.22.2 3.43.43.4 3.43.43.4 depression, depression, depression, depression, anxiety/insomnia) depression, anxiety/insomnia) anxiety/insomnia) anxiety/insomnia) depression, anxiety/insomnia) anxiety/insomnia) anxiety/insomnia) Social Frailty (0–1) Social Social Frailty Social Social Social Frailty (0–1) Frailty Frailty Social Frailty (0–1) Frailty(0–1) (0–1) (0–1) (0–1) 0.8 0.3 0.4 0.4 0.5 0.3 (social vulnerability) 0.80.80.80.80.80.8 0.30.30.3 0.30.30.3 0.40.40.4 0.40.40.4 0.40.40.4 0.40.40.4 0.50.50.5 0.50.50.5 0.30.30.3 0.30.30.3 (social (social vulnerability) (social (social Functional (social vulnerability) vulnerability) vulnerability) (social dependence vulnerability) vulnerability) for ADL,s and IADL,s 1.8 3.3 3.7 4 5.2 5.9 Functional Functional Functional Functional Functional dependence dependence Functional dependence dependence dependence dependence (0–6) 1.81.81.81.81.81.8 3.33.33.3 3.33.33.3 3.73.73.7 3.73.73.7 4 4 44 4 4 5.25.25.25.25.25.2 5.95.95.9 5.95.95.9 forfor ADL,sforfor ADL,s for and ADL,s forADL,s ADL,s and IADL,s ADL,s Frail-VIG and and and IADL,s IADL,s indexand (0–6) IADL,s IADL,s (0–6) IADL,s (0–1) (0–6)(0–6) (0–6)(0–6) 0.28 0.44 0.41 0.39 0.52 0.53 Frail-VIG Frail-VIG Frail-VIG Frail-VIG index Frail-VIG index Frail-VIG The (0–1) index index profiles index (0–1) index (0–1) are (0–1) (0–1) 0.28 (0–1)according ordered 0.28 0.28 0.28 to 0.28 the0.28 0.44 similarity 0.440.440.44 0.44 between 0.44 them. 0.41 0.41 The 0.41 0.41 0.41 darker0.41 0.39 0.39 the color, 0.39 0.39 the 0.39 0.52 0.52 0.39 frequencies higher 0.52 0.52 0.52or0.52 values0.53 0.53 of 0.53 the 0.53 0.53 0.53 variables. TheThe profiles The The The profiles Frail-VIG are profiles profiles profiles The areordered profiles are are index, are ordered ordered ordered are higher ordered according scores according according ordered according represent according to to thethe toto according to the asimilarity similarity the higher similarity the tosimilarity the degree similarity between between similarity of between between frailty. between them. them. between The them. them. Abbreviations: them. Thedarker The them. The The darker the darker darker darker The the ADLs, color, thethe the color, darker the Activities color, color,higher the color, the the the of higher color, the Daily higher higher the Living; frequencies higher frequencies orIADLs, frequencies frequencies higher frequencies values or Instrumental or values frequencies or values orvalues values or values of of theof the of the Activities variables. of the variables. variables. variables. theofvariables. the variables.of Frail-VIG Daily Frail-VIG Frail-VIG Frail-VIG Living. Frail-VIG index, higher index, index, index, Frail-VIG higher scores higher higher index,index, higher scores represent scores scores higher represent scoresscores represent a represent represent higher a higher represent a adegree higher higher a higher degree a higher ofdegree degree degree frailty. of of frailty. of degree Abbreviations: frailty. frailty. of frailty. Abbreviations: Abbreviations: ADLs, Abbreviations: of frailty. Abbreviations: ADLs, Abbreviations: Activities ADLs, ADLs, ADLs, Activities Activities of Activities ADLs, Activitiesof ofof ofof Activities Daily Daily Living; Daily Daily Daily Living; Daily IADLs, Living; Living; Living; IADLs, Living; IADLs,Instrumental IADLs, IADLs, IADLs, Instrumental Instrumental Activities Instrumental Instrumental Activities Activities Instrumental of Activities Activities Daily of Daily of Living. ofof1Daily Activities Profile Daily Daily ofLiving. Living. Living. Daily Living. (25.7%). Living. Mainly women with mild frailty, social vulnerability, moderate multimorbidity and dependence for activities of daily living. This was the most numerous Profile ProfileProfile 1 Profile (25.7%). Profile Profile profile.1The1(25.7%). 1 (25.7%).1(25.7%). Mainly 1(25.7%). Mainly (25.7%). mean Mainly women Mainly Mainly age women Mainly of women womenwith women with women participants mild inwith with withmild frailty, mild with mild this mild mild frailty, social frailty, frailty, frailty, profile social was vulnerability, social social frailty, social 87.7 vulnerability, vulnerability, moderate vulnerability, social vulnerability, and moderate moderate moderate vulnerability, they were moderate moderate primarily female multimorbidity multimorbidity multimorbidity multimorbidity and multimorbidity Itdependence and multimorbidity (76.4%). and and was and dependence dependence dependence dependence and the for dependence only activities for for for profile for activities activitiesofmild activities for with daily activities of activities of of dailyliving. dailydaily offrailty daily living. of dailyThis living. living. living. and was This living. This the This This was onethe was wasmost the This was the the most the withwas numerous most most numerous numerous most the the numerous most numerous lowest numerous prevalence profile. profile. The profile. profile.of mean profile. The profile. TheThe The mean age mean The cognitivemean mean ageof mean ageparticipants ageage of of age impairmentofofparticipants participants in in ofparticipants participants this participants (12.3%). inprofile in in this inthis this profile this was profile profile profile this However, was87.7 was profile wewas was 87.7and 87.7 87.7 and 87.7 was they and and they and 87.7 highlighted were they they were they and primarily were were they were social primarily fe-fe-fe- primarily primarily were primarily fe- primarily vulnerability fe-fe- among the majority (78.3%) and the higher percentage of cases living alone (40.6%) compared to the other profiles. 28.3% of the cases had three or more chronic diseases in target organs, the most prevalent being cardiac (55.7%) and renal (52.8%). This profile had the least dependence in regard to ADLs and IADLs (moderate-low) and the least accumulation of geriatric syndromes, with falls (25.5%) and chronic wounds (9.4%) being significant. Mortality at one year (13.2%) was the lowest of the six profiles identified. Profile 2 (1.0%). People with moderate frailty affected by advanced cancer. This was the least numerous profile, as it only applies to four participants. Nevertheless, we decided to include it because of its clinical significance. The mean age was 83.8, and half were women. The participants were moderately dependent in regard to ADLs and IADLs. This group had the lowest social vulnerability, and all participants lived with someone. The degree of frailty was moderate, with a FI of 0.44. Mortality at one year was 100%. Profile 3 (24.5%). Mainly people with moderate frailty, moderate dependence, cardiac disease and high multimorbidity. This was the second most numerous profile. The mean age was 86.1 and 56.4% of cases were women. The main characteristic of this profile was the high level of multimorbidity: half of the people had three or more chronic diseases in target organs, with the highest proportions in heart disease (84.2%), kidney disease (55.4%), respiratory disease (47.5%) and neurological disease (47.5%). It also had the highest rate of advanced chronic disease (17.8%). There was mild cognitive impairment among 23.8% of J. Clin. Med. 2021, 10, 2106 7 of 12 cases, and moderate-high dependence for ADLs and IADLs. 43.6% of cases were socially vulnerable, and 14.9% lived alone. A quarter of the participants had experienced falls and 12.9% had chronic wounds. The degree of frailty for this profile was moderate (FI 0.41). Mortality at one year was 29.7%. Profile 4 (22.3%). Primarily nonagenarian women with moderate frailty, mild cognitive impairment and moderate-high dependence. This was one of the most numerous profiles, the oldest (a mean age of 92.7) and mainly women (84.8%). It was characterized by the high presence of mild cognitive impairment (83.7%) and moderate-high dependence for ADLs and IADLs. Social vulnerability was present in 39.1% of cases, with 6.5% living alone and 29.3% with a 24-h informal caregiver. 16.3% of the cases had three or more chronic diseases in target organs, the most prevalent being kidney (62.0%) and renal (40.2%) diseases. 21.7% of cases had three or more geriatric syndromes, with rates of delirium at 46.7%, falls 35.9% and ulcers 22.8%. All this implied a moderate degree of frailty (FI 0.39). Mortality at one year was 29.3%. Profile 5 (15.8%). Mainly men with severe frailty, moderate-high multimorbidity and high dependence. The mean age under this profile was 87.9, and a minority were women (46.1%). They had a high proportion of moderate cognitive impairment (89.2%), and severe dependence for ADLs and IADLs. This was the second most socially vulnerable profile, at 53.8%. 7.7% of the people in this profile lived alone and 27.7% lived with an informal caregiver. 46.2% of cases had three or more chronic diseases in target organs, the most prevalent being cardiac (78.5%), neurological (61.5%) and renal (46.2%) diseases. Half of the people had three or more geriatric syndromes, with 56.9% having delirium. This profile had the highest proportion of falls (36.9%) and chronic wounds (36.9%). All of the above reflected a degree of severe frailty (FI 0.52). Mortality at one year was 52.3%. Profile 6 (10.7%). Mainly women with severe frailty, cognitive impairment, dyspha- gia and total dependence. The cases in this profile were mainly women (77.3%), with a mean age of 84.4 years. We found the highest rate-93.2%-of cognitive impairment (moder- ate/severe) and total dependence for ADLs and IADLs. Social vulnerability was indicated in 29.5% of cases, and it was the profile with the highest percentage of permanent informal caregivers at 31.8%. This profile had the lowest burden of overall multimorbidity, with a predominance of neurological disease (52.3%) as well as over half the cases having three or more geriatric syndromes, with higher rates than under the other profiles for dysphagia (75%) and delirium (63.6%). Chronic wounds were also present in a third of cases. All of the above implied severe frailty (FI 0.53). Mortality at one year was 43.2%. 4. Discussion The aim of the study was to identify frailty profiles among older people users of a home-based primary care service from a multidimensional perspective (physical, psycho- logical and social). We identified six frailty profiles. Three of these profiles corresponded to a moderate frailty degree, two to a severe frailty degree and one to a mild frailty degree. In addition, almost three quarters of the study population were clustered into three profiles (profiles 1, 3 and 4) that corresponded to mild and moderate degree of frailty. It is they, therefore, who could benefit from planning frailty-prevention activities. The profiles identified reveal underlying problems among the different domains of frailty and interrelated concepts (morbidity and dependence). These confirm the complexity of frailty, which is not sufficiently captured from measuring the degree of frailty and the distinction between the different domains affected (physical, psychological and social). These results are in line with three previous studies that looked at profiles of peo- ple living in the community using a multidimensional assessment approach. Lafortune et al. [14] identify four profiles based on the assessment of physical and cognitive dimen- sions: relatively healthy, physical-cognitive impairment, significant physical impairment and significant cognitive impairment. Armstrong et al. [15] identify seven profiles among home-based rehabilitation clients, based on an assessment of physical, cognitive and social dimensions: people living alone and requiring assistance with housework and bathing; J. Clin. Med. 2021, 10, 2106 8 of 12 cognitively intact people who are independent in regard to ADLs; people requiring assis- tance with IADLs and bathing; women requiring assistance with IADLs; women requiring assistance with IADLs and some ADLs; people who are dependent but mobile and have cognitive problems; people who are dependent and immobile with cognitive problems. Looman et al. [16] identify six profiles based on physical, cognitive, and social functioning: relatively healthy; mild physical frailty; psychological frailty; severe physical frailty; med- ically frail; and multi-frail. All three studies identify a profile of relatively healthy older people, which did not appear in the present study. This could be related to the fact that the study population was composed of people included under a home-care program, who present greater vulnerability. In another recent study [32], three functional groups of older people at risk of disability are identified: physical, social and mixed. The psychosocial group, however, includes variables from the psychological and social dimensions, which can make it difficult to plan differentiated preventive or management activities. The vast majority of frailty research that focuses on people’s outcomes is based on adverse outcomes, such as mortality, dependence, hospitalization and institutionalization. Outcomes related to positive aspects such as well-being and quality of life are less stud- ied [24,33]. In our study, we have analyzed both negative outcomes (mortality, dependence, polypharmacy) as well as a positive outcome (quality of life). Frail older people can also present improvement in their quality of life. Therefore, the information will also serve to personalize the care plans based on a positive approach. The main strength of this study is the statistical technique applied to determine the profiles, as well as the standardized data collection, using simple measurement instruments that are commonly used in healthcare practice. This pragmatic perspective would be feasible and capable of being extrapolated to larger populations. Another strong point is the differentiation between the concepts of frailty, morbidity and dependence, as it helps with planning care that is better aligned with needs. Where there is morbidity, activities will be planned to prevent or reduce frailty; where there is frailty, activities will be planned to prevent adverse outcomes, such as dependence [21]. 4.1. Limitations and Future Research Recommendations The main limitation of the study is that although the sample studied was large and all possible participants have been included, it corresponds to an aging population in an urban area with a medium-high socio-economic level, which makes it difficult to generalize the results to other settings or populations. Moreover, the Frail-VIG index is a simple and feasible instrument for use in the care setting, albeit with some limitations: the variables that correspond to physical frailty are focused on geriatric syndromes (weight loss, dysphagia, falls, ulcers) and do not include other variables that are recognized for identifying physical frailty. Here, the reference model would be Fried’s phenotype [9]. Future studies should contrast the results obtained in relation to other populations included under home-care programs with different socio-cultural levels and analyze other environments (for example, residential). It would also be useful to assess aspects of social frailty in greater depth. We suggest that this should include the three main components identified in a recent review: threat or absence of social resources to meet basic social needs; threat or absence of social behaviors and social activities; and threat or absence of self-management skills [34]. 4.2. Care Implications and Outlook for the Future The multidimensional nature of frailty has resulted in the identification of heteroge- neous profiles, under which it would be useful to adapt care plans in health care practice. The multidimensional impact of frailty justifies multicomponent interventions [35–37]. Indications for multimorbidity management should also take account of health priorities, assess the potential benefits of interventions against potential harms, identify the person’s health trajectory, and encourage shared decision making, aligning people’s wishes and professionals’ opinions [1,38]. An effective overall management approach would include J. Clin. Med. 2021, 10, 2106 9 of 12 physical activity, nutritional supplementation, cognitive training, structured medication review, and social reinforcement. This approach shares similarities with other programs studied in our healthcare setting with the resources available in community care and other devices in the territory [39–41]. Table A1 in appendix shows, as an example a pragmatic proposal of care objectives and interventions for the different profiles identified, according to the current evidence for the management of frailty [35–37] and the multimorbidity [1,38]. Finally, it would also be helpful to include the opinions of the people cared for at home, their family members and caregivers on the profiles identified, as well as the care plans proposed for each of them. 5. Conclusions This study identified six profiles of frailty, with clinical interest in older people users of a home-based primary care service. It shows that the population included under the home- care program is heterogeneous and has different care needs. Identifying these profiles complements information on degrees of frailty as it enables different care needs to be ascertained for people who are identified as having the same degree of frailty and is useful when designing interventions that are aligned with the needs of each population profile. Author Contributions: Conceptualization, J.-J.Z.-S., E.Z.-d.-O. and S.F.-B.; data curation, J.-J.Z.-S.; formal analysis, J.-J.Z.-S., E.Z.-d.-O. and S.F.-B.; funding acquisition, J.-J.Z.-S.; investigation, J.-J.Z.-S.; methodology, J.-J.Z.-S. and J.A.-N.; project administration, J.-J.Z.-S.; resources, J.-J.Z.-S.; supervision, E.Z.-d.-O., V.G.-C. and I.J.-R.; visualization, J.-J.Z.-S., E.Z.-d.-O. and S.F.-B.; writing—original draft, J.-J.Z.-S.; writing—review and editing, J.-J.Z.-S., E.Z.-d.-O., S.F.-B., V.G.-C., I.J.-R. and G.P.-T. and J.A.-N. All authors have read and agreed to the published version of the manuscript. Funding: J.-J.Z.-S. was supported by a PERIS grant from the Departament de Salut de la Generalitat de Catalunya (the Catalan Regional Government’s Health Department), Spain for the period 2019-20 registration number SLT008/18/00011. Institutional Review Board Statement: The study was conducted according to the guidelines of the Declaration of Helsinki, and approved by the Jordi Gol i Gorina Ethics Committee (code: P17/150; date 6 November 2017). Informed Consent Statement: Informed consent was obtained from all subjects involved in the Study or by family members in the case of advanced dementia. Data Availability Statement: The data presented in this study are available on request from the corresponding author. The data are not publicly available due to ethical reasons. Acknowledgments: The authors of this study would like to thank all the professionals who helped with collecting the data, in particular the nurses of the home-care unit of the Montnegre Primary Care team. Conflicts of Interest: The authors declare no conflict of interest. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results. Conflicts Conflicts Conflicts Conflicts of Conflicts Interest: of ofof of Interest: Interest: Conflicts The Interest: Interest: of authors The The The The authors authors Interest: Theauthors declare authors declare authorsdeclare declare nodeclare conflict no no no conflict no conflict declare conflict of conflict interest. of no ofof interest. conflict interest. of interest. The interest. funders The of The The The funders interest. hadfunders funders funders had The no had role no had funders had noinhad role norole role no the in role in the no ininthe the role thethe in design design design design of the design of study; theof ofofstudy; the study; design the the inof the in study; study; thethe inincollection, collection, in the thethe the collection, study; in collection, collection, analyses, analyses, analyses, analyses, or analyses, collection, ororinterpretation interpretation oranalyses, interpretation or interpretation interpretation or of data; of data; interpretation ofofdata; ofindata; the in data;ininwriting writing indata; the of the the the writing writing of the in writing the of manu- ofofmanu- of the the manu- writing thethe the of manu- manu- manu- script, or in script, orscript, script, script, the inor inoror decision the script,the in indecision the decision or the in decision tothe decision publish topublish to publish to decision publish to the publish results. the to the thethe results. results. the results. publish results. results. J. Clin. Med. 2021, 10, 2106 Appendix Appendix A A A AA Appendix Appendix Appendix 10 of 12 Appendix A Table A1. Table Table A1.Table Table A1. A1. Proposal A1. Proposal Table Proposal Proposal for Proposal A1. care for for care forcare care objectives care for objectives Proposal for objectives objectives and objectives careand and interventions interventions and and interventions interventions for interventions objectives and each for forsix each interventions for each for each profiles sixeach sixprofiles sixeach profiles profiles six identified. profiles for identified. identified. identified. identified. six profiles identified. Appendix A Profiles Profiles Profiles Profiles Profiles Profiles Proposal Table A1.Profile 1for Profile 1care Profile 1 Profile Profile objectives 1 1Profile Profile 1Profile Profile andProfile 2Profile 2 Profile 2interventions 2 Profile 2Profile Profile 3Profile 23 Profile 3for 3Profile 3each 3 Profile Profile Profile six 4 Profileprofiles 4Profile 4Profile 5identified. 4 4Profile 4Profile Profile 5Profile Profile 55 Profile 5Profile Profile 6Profile 6 66 6 56 Profile Profile Profile Profiles Profile 1 Profile 2 Profile 3 Profile 4 Profile 5 Profile 6 Objectives ObjectivesObjectives Objectives Objectives andand and Activities and andand Activities Activities Objectives Objectives Activities Activities and Activities Activities Priority Priority Priority Priority Objective Priority Priority Objective Objective Priority Objective Objective Objective Objective (A)(A) (A)Survival Survival (A) Survival (A) Survival (A)(A) Survival Survival Survival A–B C B–A B–A C–B C–B (B) Preserve and enhance A–B A–BA–BA–B A–BA–B C C C CCB–A C B–AB–AB–A B–A B–A B–AB–AB–A B–A B–A C–B B–A C–BC–BC–B C–B C–B C–B C–BC–BC–B C–BC–B Preserve (B) Preserve(B) (B) Preserve (B)and (B)Preserve Preserve enhance and and and enhance Preserve autonomyand enhance enhance autonomy enhance and autonomy autonomy enhance autonomy autonomy autonomy )(C) Wellbeing (C) (C)(C) Wellbeing (C) Wellbeing Wellbeing Wellbeing and andsymptom and symptom Wellbeing (C) Wellbeing and and symptom symptom control symptom and and controlcontrol symptom control control control symptom control GroupGroup Group Group Group Individual Individual Group Individual Individual Individual GroupGroup Individual Group Group Group Group Group Group Group Group Group Individual Individual Individual Individual Group Individual Individual Individual Individual Individual Individual Individual Individual Group Individual Group Group Individual Individual activity activity activity activity activity personalised personalised activity personalised personalised personalised activity activity personalised activity activity activity activity activity activity activity activity activity personalised personalised personalised personalised personalised activity personalised personalised personalised personalised personalised personalised personalised Physical Physical Physical Physical Physical activity Physical activity activity activity planning Physical activityplanning activity planning planning activity planning planningactivity planning personalised activity activity personalised personalised according according toaccording according toto toto to according accordingto according comorbidity comorbidity comorbidity comorbidity comorbidity comorbidity comorbidity Promote Promote Promote Promote Promote self-care Promote self-care self-care self-care Promote self-care self-care self-care ++ ++ ++ ++ ++ +++++ + + + ++ +++ + +++++++++ +++ ++ ++ ++ ++ ++++++ ++++++− − − −−− −− − − −− − − Maintenance of autonomy +++ ++ +++ +++ + + Maintenance Maintenance Maintenance Maintenance Maintenance of autonomy of of autonomy of autonomy Maintenance Technical autonomy of autonomy help/home of autonomy ++++++ +++ +++ +++ +++ ++ ++ ++ ++ +++ ++ +++ ++ +++ +++ +++ +++ ++++++ +++ +++ +++++++ + + ++ ++ + + ++ + echnical Technical Technical Technical help/home Technical help/home help/home Technical help/home help/home adaptations adaptations adaptations adaptations adaptations help/home adaptations adaptations ++ + + ++ +++ ++ ++ ++ ++++++ + + ++ ++ ++ + + +++ +++ ++ ++ ++++ ++ ++ ++ ++ ++ ++++++ ++ Healthy Healthy Healthy diet HealthyHealthy diet Healthy dietdietdiet Healthy diet diet DietDiet Diet DietDiet Healthy Healthydietdiet diet Healthy Healthy diet/on diet/on demand demand Diet, and nutritional Nutritional Diet DietHealthy Healthy Healthy diet Healthy diet diet Healthy Healthy diet Healthy Healthy diet/on Healthy diet/on diet/on demand Healthy diet/on demand demand diet/ondemand demand Nutritional Nutritional Nutritional Nutritional Nutritional Nutritional iet, and Diet, Diet, and Diet, nutritional Diet, and and and nutritional supplements nutritional nutritional Diet, nutritional and supplements supplements supplements supplements nutritional supplements supplements supplements on demand Nutritional supplement Nutritional supplement supplements supplements supplements supplements supplements on on demand demand supplements ondemand on demand on ondemand Nutritional Nutritional demand Nutritional Nutritional Nutritional supplement supplement Nutritional adapted supplement tosupplement supplement Nutritional supplement comorbidity Nutritional Nutritional NutritionalNutritional supplement tosupplement supplement supplement Nutritional adapted supplement supplement comorbidity Prevention and adapted adapted adapted to adapted adapted comorbidity to to tocomorbidity comorbidity adapted comorbidity comorbidity to to adapted adapted adapted comorbidity to adapted adapted comorbidity to to tocomorbidity comorbidity comorbidity to comorbidity adapted to comorbidity + ++ + + ++ +++ ntion Prevention Prevention eventionand and management Prevention management and andand management management Prevention ofofdysphagia management management and dysphagia ofofdysphagia of dysphagia of dysphagia management dysphagia of + + + ++ +++ ++ ++ ++++++ dysphagia + + + ++ ++ + + ++ +++ ++ ++ ++++++ ++++++ +++ +++ ++++++ Cognitive stimulation + − + ++ ++ − Cognitive Cognitive Cognitive Cognitive Cognitive stimulation Psychological stimulation stimulation stimulation Cognitive stimulation stimulation intervention + + + ++ + − − − −− −+ + + ++ ++ + ++ ++ ++++++++ ++ ++ ++++++− − − −− − ychological Psychological Psychological Psychological Psychological intervention intervention intervention intervention intervention (Depres- (Depres- (Depres- (Depres- (Depres- ++ +++ +++ ++ ++ − Psychological (Depression/Anxiety) intervention (Depres- Prevention and ++ ++ ++ ++++++ ++++++ +++ +++ ++++++ ++++++ +++ +++ ++++++ ++ ++ ++ ++++++++ ++ ++ ++++++− − − −− − sion/Anxiety) sion/Anxiety) sion/Anxiety) sion/Anxiety) sion/Anxiety) sion/Anxiety) − + + ++ ++ +++ management Prevention and of delirium of delirium management ention Prevention Prevention evention and management and and and management management Prevention management and of delirium of delirium of delirium management of delirium − − − −− − + + + ++ ++ + + ++ ++ of delirium + ++ ++ ++++++++ ++ ++ ++++++ ++++++ +++ +++ ++++++ Therapeutic adequacy and apeutic Therapeutic Therapeutic Therapeutic erapeutic adequacy adequacy adequacy Therapeutic andadequacy adequacy anddeprescription deprescription and andand deprescription deprescription deprescription adequacy deprescription and ++ + + ++ +++++++ deprescription +++ +++ +++ +++++++ + ++ ++ ++ + ++ ++ ++ ++++++ ++++++ +++ +++ +++ +++ ++++++ +++ +++ +++ ++++++ +++ Social Social Social intervention Social Social intervention Social intervention intervention intervention intervention Social intervention ++++++ +++ +++ +++ ++++++ ++++++ +++ +++ +++++++ + ++ ++ ++ + + +++ +++ ++ ++ ++++ ++++ ++ ++ ++ ++++++ Palliative Palliative Palliative Palliative Palliative needs Palliative needs needs care needs Palliative needs care care needs care needs care care care ++ + + ++ ++++ + ++++ ++++++++++++++++ + + ++ ++ ++ + + +++ +++++++ +++ +++ ++++ +++ +++ ++++++ +++ +++ +++ ++++++ +++ Advance care planning + ++++ ++ ++ +++ +++ Advance Advance Advance careAdvance Advance planning care care Advanceplanning Caregiver support care care planning care planning planning planning + + + + + + ++++ + ++++ +++ ++++ ++++ ++++ ++ ++++ ++ ++ ++ ++++ ++ ++ ++ ++ ++ ++ ++ +++++ +++ +++ +++ +++ +++ +++ +++ +++ +++ +++ +++ +++ +++ Caregiver Caregiver Caregiver Grief Caregiver Caregiver support support support Caregiver management support support in support the + + + ++ +++++++ +++ +++ ++++++ ++ ++ ++ ++++++ ++ ++ ++ ++++++ ++++++ +++ +++ ++++++ ++++++ +++ +++ ++++++ rief Grief management GriefGrief management Grief in patient’s management management managementthe in the management family ininpatient’s patient’s in the the the patient’sin patient’s family patient’s the familyfamily family family patient’s + family ++++ ++ ++ +++ +++ environment + + + ++ ++++ + ++++++++++++ ++++ ++ ++ ++ ++++++ ++++ ++ ++ ++ ++++++ ++++++ +++ +++ ++++++ ++++++ +++ +++ ++++++ environment environment environment environment environment environment Degree Degree Degree ofDegree ofDegree of intensity Degree intensity Degree ofof intensity of intensity intensity ofintensity the proposed of the ofintensity of the of the proposedof the ofofproposed the theproposed proposed interventions: proposed interventions: proposed interventions: interventions: interventions: interventions: minimum minimum minimum minimum interventions: minimum minimum intensity intensity intensity (−), intensity minimum intensity mild (−), −), (mild intensity (−), mild (−), intensity mild (−), intensity intensity mild mild intensity intensity (−), (+), (+), intensity intensity mild moderate moderate (+), (+), moderate (+), moderate intensity intensity (+),intensity moderate moderate (+), (++), intensity intensity(++), moderate intensity high (++), high intensity (++), intensity (++), (++), high intensity high high high (++), (+++), high very high intensity (+++),intensity very (++++). high intensity (++++). ntensityintensity intensity(+++), intensity very (+++), (+++), (+++), very intensity highvery highintensity very (+++),high high intensity intensity very (++++). intensity high (++++). 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