MULTIMORBIDITY PATTERNS OF THE FRAGILITY PHENOTYPE IN OSTEOPOROSIS

It was highlighted that the osteoporosis and co-morbidities can lead to the worse of the frailty nursing homes elderlies through the various aspects. An association was observed between FRAX, low level of 25 OH Vitamin D and geriatric syndromes with an increased risk of falls and hip fracture at the frails group. According to the cluster analysis (k-means method), the most relevant indicators that separated the clusters were: age category, gender, clinical scale of frailty, comorbidities, geriatric syndromes and daily drugs used. The results obtained characterize the profile of institutionalized elderlies and can be used as a basis for the development of effective strategies, aimed at reducing physical, cognitive and social frailty.


Introduction
Increased life expectancy and improved health records systems have resulted in an expanded population with diagnosed comorbidities and geriatric syndromes (GSs) [14,19]. It is estimated that more than 95% of people older than 65 years in western countries will have coexisting diagnoses of two or more diseases at some point in time [13].
The combination of multimorbidity marks older peoples' frail state by the increasing risk of cognitive, functional and mobility impairment, which are identified across five common geriatric syndromes (pressure ulcers, incontinence, falls, functional decline, and delirium), hospitalizations, polypharmacy, placing in nursing homes and worsening quality of life, translating into a substantial economic burden for public health systems [2].
GSs have been defined as multifactorial health conditions that contribute to older peoples underlying frailty, being varios and prevalent among communitydwellers, they are difficult to manage clinically, and put older people at increased risk not only for developing new chronic conditions, but also for placing in nurses homes [16,17]. Acting on these syndromes may prevent serious deterioration of existing chronic conditions, as well as the decline in activities of daily living, it is necessary for health care professionals to provide interventions not only to control diseases, but to restore or maintain physical function and prevent or reduce disability [6].
Osteoporosis, pain on low back, knee, and spinal deformity were reported to be risk factors for locomotive geriatric syndrome (LoGS) [10,12]. Several physical performance tests such as timed up and go test, back muscle strength, gait speed, grip power, the short physical performance battery, vulnerable elders survey test, Charlson and Gröningen frailty scor, were proved to be valid for identification of LoGS [12].
A lot of studies have examined the prevalence of multimorbidity, with methods for estimation ranging from descriptive statistics of the number of diseases per individual to large-scale classification systems for the measurement of morbidity burden and case-mix [19].
A number of relevant studies have been published in the last few years, and 248 there is an urgent need to establish what is currently known about the determinants and prevalence of multimorbidity and the most frequent patterns observed in primary care [9].
The aim of this study was to highlight and identify the main multimorbidity patterns of the frailty phenotype in osteoporosis using statistical processing methods to identify valuable information indices and establish the associative links of frailty subtype through the cluster and correlational methods.

Material and methods
The epidemiological study was part of the Institutional Project
In the specialized works of the last years, the researchers reported the The method of building dendrograms is widely used in medicine, but this is appropriate for relatively small batches of patients [11]. In our case, (fig. 5)  Linkage Distance

Fig. 5. Dendrograma distribution of the frailty elderls in clusters
The k-means method is convenient in that the user determines the number of clusters in which patients are to be classified by possible categories in the diapazon: weak-strong, little-much, etc., etc. In the present study, we aimed to elucidate the frequency of relevant clinical manifestations that would serve as markers of the evolution of subtype frailty status depending on osteoporosis and geriatric syndromes ( fig. 6). At the same time, applying the k-means cluster analysis, elderlies was divided into 3 sublots according to frailty phenotype, using 47 different parameters, the most relevant indicators was: age category, gender, fragility subtype, number of chronic polypathologies and daily polymedications used, which can be easily applied in trials clinics by the clinicians (Tab.1).

Table 1
Cluster analysis of of the subtype frailty status depending by category of age, gender, comorbidities and drugs.

Conclusions
Following a multilateral research, it was highlighted that the osteoporosis and co-morbidities can lead to the worse of the frailty nursing homes elderlies through the various aspects. To our knowledge, this is the first study to describe a strong association between multimorbidity with osteoporosis in fragility phenotype. The robust, prefrail and frail elderlies groups, positive and negative associated correlates of poor physical performance, mental disorders, chronic health problems, which suggest the need for early detection and prevention measures in order to control frailty. An association was observed between FRAX, low level of 25 OH Vitamin D and geriatric syndromes with an increased risk of falls and hip fracture at the frails group. According to the cluster analysis (k-means method), the most relevant indicators that separated the clusters were: age category, gender, clinical scale of frailty, comorbidities, geriatric syndromes and daily drugs used. The results obtained characterize the profile of institutionalized elderlies and can be used as a basis for the development of effective strategies, aimed at reducing physical, cognitive and social frailty. The current geriatric medicine protocols of the Republic of Moldova should be revisited to address these problems using a holistic approach to health care, focusing not only on a specific disease, but on the multidimensional assesment.