1. Introduction
One of the issues of interest in geriatric medicine circles is aging syndromes. These syndromes are a group of very common features in the elderly but are not considered diseases. One of these syndromes is frailty [1]. Frailty syndrome is an aging condition with various causes and risk factors that can lead to disability in the elderly [2]. Frailty is caused by increased vulnerability to stressors due to loss of physiological reserves in various body systems [3, 4]. It is accompanied by adverse health outcomes such as weakness, decreased performance, hospitalization, increased use of medical centers services, numerous physician referrals, and polypharmacy [3, 5]. Due to the importance of frailty syndrome and various factors involved in the clinical condition of the elderly, especially polypharmacy, this study aimed to investigate the relationship between fertility syndrome and polypharmacy in the elderly referred to the emergency departments of Ardabil educational and medical centers in 2019.
2. Methods
The present study is descriptive-analytical. The research population was the elderly aged 60 years and older who were referred to the emergency department of Ardabil educational and medical centers in 2019. A sampling method was available. Inclusion criteria include; willingness to participate in the study, Iranian citizenship and resident of Ardabil, no severe hearing or vision problems, no cancer, no history of debilitating diseases such as severe heart failure or stroke, no use of mobility aids, no severe cognitive and psychiatric disorders cited by the individual and the family. Exclusion criteria also include; Unwillingness to cooperate at any stage of the study, those who were medically prohibited from measuring walking speed and hand strength, and those unable to speak.
Data collection tools included demographic information questionnaire including age, gender, marital status, education, lifestyle arrangements, number of drugs used in 24 hours, smoking history, economic status, number of emergency visits, number of chronic diseases, number of hospitalizations, and frequency of 115 emergency calls. The number of drugs used in 24 hours was taken and divided into three categories to evaluate polypharmacy in the elderly: non-polypharmacy (0-4 drugs), polypharmacy (5-9 drugs), and hyper-polypharmacy (≥10 drugs) [16]. To determine frailty in the elderly, the indicators defined by Fried et al. [8] were used, which include 5 items: 1), Exhaustion 2), Grip Strength 3), Walk Time 4), Level of physical activity 5), Unintentional weight loss. Data were analyzed using descriptive statistics, including mean and standard deviation, and inferential analysis, including analysis of variance, independent t-test, and multiple regression using SPSS 22 statistical software.
3. Results
Of the 505 elderly participants in the study, 255 (50.5%) were male, 318 (63%) were married, and 271 (53.7%) were illiterate. 279 (55.2%) lived with their spouses, and 326 (64.6%) of the elderly did not smoke. 287 people (56.8%) were economically dependent. 247 of the elderly (48.9%) had been referred to the hospital emergency department at least once, and 230 (45.5%) had no hospitalization history. Also, 256 patients (50.7%) had no contact with 115 emergencies. 267 (52.9%) of the elderly had between 3-4 chronic diseases. The average number of drugs used by the elderly was 6.30 ±2.61. 204 (40.4%) of the elderly referred to the emergency department were frailty, 177 (35%) pre-frailty, and 124 (24.6%) were non-frailty (Table 1).



The independent t-test results showed a significant relationship between gender, education, and economic status with frailty, but no statistically significant relationship was observed with smoking. Also, according to the one-way analysis of variance test, there was a significant relationship between marriage, age, living arrangements, emergency department and hospitalization, frequency of 115 emergency calls, and the number of patients with frailty (P˂0.05). The correlation test results showed a positive and significant correlation between frailty syndrome and polypharmacy, so that frailty elderly had the highest percentage of polypharmacy and hyper-polypharmacy. Also, the rate of drug use in the frailty elderly was higher than in the non- frailty elderly.
Linear regression analysis was used to investigate the simultaneous effect of each variable affecting frailty. According to the results, the relationship between age (ß=0.50), life arrangements (ß=0.09), number of hospitalizations (ß=0.10) and number of drugs (ß=0.17) and frailty syndrome was a positive and significant correlation, and the relationship between education level (ß=-0.13) and frailty syndrome was a negative and significant correlation. According to the obtained determination coefficient, 0.58% of the frailty changes were due to the variables mentioned in the model. The performed regression model had an acceptable fit (F=56.56, P˂0.001).
4. Discussion 
The variables of age, education, lifestyle arrangements, hospitalization, and the number of drugs used were predictors of frailty syndrome in the elderly referred to the emergency department. Due to the increase in life expectancy and the increase in the elderly population, the prevalence of frailty will affect developing countries in the future. Therefore, a suitable policy in patient management in emergency departments can be an excellent way to overcome the challenge of frailty syndrome. It is suggested that as a key indicator in the elderly clinical examination, especially in health care centers, particular attention be paid to frailty and polypharmacy syndromes, and by developing an appropriate program in these centers to prevent or reduce the progression of these two syndromes, appropriate measures should be taken. Also, due to the frequent referrals of the elderly to the emergency department, it is recommended that the assessment of frailty syndrome and polypharmacy be evaluated upon arrival in the hospital triage units.
Ethical Considerations
Compliance with ethical guidelines
This article is approved by Ardabil University of Medical Sciences with the code of ethics IR.ARUMS. REC.1398.456 has been approved.
Funding
This is taken from Hossein Asadi's master's thesis in the Department of Nursing, School of Nursing and Midwifery, Ardabil University of Medical Sciences, Ardabil.
Authors' contributions
Conceptualization, Methodology, Investigation, and Writing – original draft: Aghil Habibi Soola and Hosein Asadi; Writing – review & editing, Aghil Habibi Soola, Hosein Asadi, and Sohrab Iranpour; Analysis: Aghil Habibi Soola, Sohrab Iranpour; Resources and Supervision: All author.
Conflicts of interest
The authors declared no conflict of interest.
Acknowledgments
We sincerely thank all the staff of the emergency department of Imam Khomeini, Imam Reza, Alavi and Fatemi hospitals in Ardabil and the elderly who participated in the present study.