Table 4 shows the different lipid profile patterns of admitted frail Filipino elderly. Among 131 dyslipidemic patients, 50% have hypercholesterolemia, 60% has hypertriglyceridemia, 21% have decrease HDL levels and 41% have elevated LDL levels. 61% of them have multiple combinations of abnormal lipid profile patterns (Table 4).

Table 5: Demographic profile of frail elderly Filipino patients with & without dyslipidemia.

Table 5 presents the demographic data of the respondents. Out of 188 frail elderly Filipino patients 89 (47.3%%) were females and 99 (52.7%) were males. There was significant association noted on frail elderly dyslipidemia Filipino patients with coronary artery disease with p-value of <0.05. Other demographic variables such as hypertension, cerebrovascular Disease/CVD, peripheral arterial occlusive disease, chronic kidney disease/CKD, diabetes mellitus, dementia, respiratory disease: COPD bronchial asthma, liver disease, malignancy,

Table 6: Clinical outcome of frail elderly dyslipidemic patients in number of hospital days.

Table 7: Clinical outcome of frail elderly dyslipidemic patients in mortality rate.

Table 7 shows that there was no difference in mortality rate among dyslipidemic frail elderly Filipino patients from those without dyslipidemia with p-value of >0.05 (Table 7).

5. Discussion
Frailty is a medical condition that causes a decline in functionality and an increased vulnerability to illness. Frailty may increase the risk of dyslipidemia, a condition that involves abnormal levels of lipids in the blood. Both conditions are more common in older people. The prevalence of frailty is different base on the setting of the research, it is usually lower in the community and higher in the hospital. Studies showed that the prevalence rate of frailty in the community ranges from 6.9-24%^5,7, while in hospital setting, it showed a prevalence rate of 41-71%⁸. In a local study made by Laude T-MP et al, A total of 109 elderly was included in the study, only 8.3% were frail, 81.6% were prefrail and 10.1% are robust using Fried’s frailty criteria. It was also noted that 60.6% of participants has dyslipidemia⁹. Based on our research, 72% of our elderly admitted patients were frail.

In our study, the prevalence rate of dyslipidemia who are frail elderly is 69.65%. The prevalence rate of dyslipidemia in the Philippines, base on cut off values: borderline (200–239 mg/dL) to high TC (≥240 mg/dL), borderline (130–159 mg/dL) to high LDL-C (≥160 mg/dL), low HDL-C (<40 mg/dL) and elevated TG (≥150 mg/dL) in adults aged ≥20 years were 46.9%, 47.2%, 71.3% and 38.6%, respectively. 72% of adults in this survey had at least one abnormal lipid component¹⁰. In a study done by Rosada et al, the prevalence of hyperlipidemia was more frequent in the elderly group (76%) compared to the young group (41%). Hypercholesterolemia was the most common (64%), followed by hyperlipoproteinemia (18%), hypertriglyceridemia (7%) and combined hyperlipoproteinaemia (5%)¹¹. According to Xi, Y. et al, the age-standardized prevalence of dyslipidemia was 31.2%. The prevalence of dyslipidemia generally increased with age but was decreased in the age group 65-75 years. The same trend was observed for elevated LDL-C and TG. The prevalence of dyslipidemia was significantly higher in men than in women¹².

Lipid metabolism is altered during old age. As a result of aging, all gastrointestinal processes (such as movement, enzyme, hormone release) are altered, which in turn affects digestion and absorption, thereby leading to reduced nutrient uptake. Changes in lipid synthesis and catabolism that occur with aging lead to abnormal lipid utilization in tissues. The dysregulation of the lipid metabolism in older adults is often reflected by changes in blood lipid levels, which are associated with the onset of various chronic diseases. Specifically, the levels of triglycerides, total cholesterol and low-density lipoprotein cholesterol tend to increase, while high-density lipoprotein cholesterol (HDL- C) concentrations become relatively irregular during aging. Regarding lipoprotein levels, low-density lipoproteins have been reported to increase with age. The primary age-related change in pancreatic function is the decline of the pancreatic lipase activity. Bile acid levels showed a consistent decrease with age. The absorption of dietary fat initiates an increase in the plasma triglyceride concentration and the resultant increase in chylomicron and very low-density lipoproteins (VLDL) in the blood in the postprandial state. The dysregulation of the lipid metabolism in older adults is often reflected by changes in blood lipid levels, which are associated with the onset of various chronic diseases¹³.

In an article written by Paolo P. et al, the mechanisms behind this age-related increase in plasma cholesterol are still incompletely characterized. Of particular interest is the finding of a gradual decline in the fractional clearance of LDL from the circulation with age and evidence of the reduced expression of hepatic LDL receptors (LDLRs) with increasing age in some species. The capacity for body cholesterol removal through the conversion of cholesterol to bile acids is also progressively reduced with age and a decrease in the activity of the rate-limiting enzyme in bile acid biosynthesis, cholesterol 7α-hydroxylase, has been demonstrated in the aging rat. In addition, there is some evidence that the synthesis of apolipoprotein B-100 in VLDL may be increased with age. A number of explanations to these findings have been discussed, including both dietary and hormonal factors. An interesting hypothesis states that the critical changes in cholesterol and lipoprotein metabolism depend on the progressive decrease in growth hormone secretion, which occurs with normal aging¹⁴.

Lipid profile from the National Health and Nutrition Examination Survey (NHANES) 2003-2004 showed the comparison of lipid profile pattern from 30–79-year-olds old, there is a slight decrease in LDL, non-HDL-C and triglycerides with similar HDL levels in individuals 70-79 years of age. Other cross-sectional studies have reported similar results. Prospective studies with longitudinal follow-up have also observed small decreases in total cholesterol, LDL and HDL levels in men and women as they become elderly. It should be noted that the changes in lipid levels reported with aging are relatively small and vary somewhat from study to study. Other studies also showed that older individuals have an increase postprandial lipemia compared with younger individuals. However, the clinical significance of these small changes is uncertain. It is well recognized that as one becomes older, the likelihood of other medical disorders increases, older patients usually have multiple co-morbidities and this can affect lipid levels. For example, inflammation, infections, poor nutrition or socio-economic factors can decrease LDL and HDL levels. Finally, frailty is a syndrome associated with aging and increases with age¹⁵.

Lipid metabolism plays a role in frailty. Pathogenesis includes decreased muscle mass, reduced physical function and increased vulnerability to health issues; this is due to changes in lipid levels, particularly phospholipids, which can affect muscle function and contribute to the overall decline seen in frail individuals. In a study of Ramirez-Velez, et al, a lipidomic approach found that five circulating metabolites including ceramides, cholesterol and phosphatidylcholines were significantly increased in physically frail compared with robust older adults at hospital admission. Moreover, cholesterol and ceramides had acceptable levels of accuracy to discriminate physically frail at hospital admission and, therefore, might be useful biomarkers in clinical practice. The non-targeted metabolic study can open a wide view of the physically frail features changes at the plasma level, which would be linked to the physical frailty phenotype at hospital admission¹⁶.

In a study made by Lee WJ, et al, wherein they correlated frailty and the components of metabolic syndrome, 12.9% were frail. The prevalence of frailty and metabolic syndrome increased along with aging. Those with metabolic syndrome were strongly associated with frailty status and presenting a dose- dependent effect than their counterparts. The study demonstrated associations between frailty and metabolic syndrome and its individual components (elevated triglyceride levels) but not in low HDL-C, especially in females and older adults¹⁷. A cross- sectional investigation of the relationship between dyslipidemia and frailty showed that increased TG was associated with the development of frailty. Gale et al. found an association between high TC levels and new-onset frailty¹⁸. However, in a systemic review of association between cardiometabolic risk factors and frailty in older adults showed that there was inconsistency across the studies regarding the associations between dyslipidemia and frailty. Further studies should be done¹⁹.

In our study, the prevalence rate of different lipid profile components in our frail elderly were hypertriglyceridemia (60%), hypercholesterolemia (50%) and High LDL-C (41%) and low HDL-C (27%). Our results are much higher compared to a study done at Iran by Delbari et. al, wherein high levels of total cholesterol, triglyceride, low-density lipoprotein and low level of high-density lipoprotein were seen among 9.74%, 24.66%, 5.54%, 19.20% of their elderly participants, respectively²⁰. Reasons of this is maybe due to ethnic backgrounds, different study settings and subjects. 

Lipid profile levels in elderly may affect their functionality. The prevalence of activities of daily living disability showed downward trend with an increase of the LDL-C and triglyceride and an increase in HDL-C levels had a protective effect against activities of daily living disability²¹.

Studies showed that incidence of frailty (CFS score ≥5, mild- severely frail) was higher in those with cardiovascular disease compared to those without cardiovascular disease (76% vs 66%). A history of cardiovascular disease was significantly associated with higher rate of first readmission or death within 12 months, compared to no history of cardiovascular disease²². In a Taiwanese retrospective cohort study, older females with the lowest quartile of TC and LDL cholesterol had higher cardiovascular mortality. Older females with the lowest quartile of HDL had higher mortality from cardiovascular and cerebrovascular diseases and concluded that TC, mostly attributed to LDL cholesterol, was inversely related to all-cause mortality. HDL remained to be protective against both cardiovascular and stroke mortality in older females²³. In our study, there was significant association noted on frail elderly dyslipidemic Filipino patients with coronary artery disease than those without dyslipidemia, hence treatment of dyslipidemia is still warranted among them.

In a study done by Onder G et al, among older hospitalized adults, low serum cholesterol levels appear to be an independent predictor of short-term mortality²⁴. According to Wang, R et al. The mean total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C) and low-density lipoprotein cholesterol (LDL-C) levels in elderly were higher among those who died than among those who survived. Participants in the second HDL-C quartile and the highest LDL-C and triglyceride (TG) quartiles had 28% higher, 23% lower and 49% lower risks of all-cause mortality, respectively²⁵. Our study showed no significant association noted in the number of hospital days and mortality rate among our frail elderly dyslipidemic patient from those without dyslipidemia.

6. Conclusion
The study revealed the prevalence of frail elderly Filipino patients with dyslipidemia is high at 69.65% and the prevalence of frail dyslipidemic in specific age group is almost the same ranging from 61 to 75%. The most common lipid profile abnormality is hypertriglyceridemia at 60% among our frail elderly patients. Among co-morbidities, coronary artery disease is associated with our frail dyslipidemic elderly patients than those without dyslipidemia. This study may serve as a baseline study in the Philippines and aims to provide information on frail elderly with dyslipidemia.

7. Contributors
All authors designed the study, acquired the data, analysed the data, drafted the manuscript and critically revised the manuscript for important intellectual content. All authors had full access to the data, contributed to the study, approved the final version for publication and take responsibility for its accuracy and integrity.

8. Funding/Support
No specific grant or funding received.

9. Data Availability
All data generated or analyzed during the present study are available from the corresponding author on reasonable request.

10. Ethics Approval
Approval was obtained from the Internal Medicine department, Professional Education Training and Research Office and Review and Ethics Board of Quirino Memorial Medical Center.

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