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Reliability and validity of the Tilburg Frailty Indicator (TFI) among Chinese community-dwelling older people
Abstract
Objective:
To translate the Tilburg Frailty Indicator (TFI) into Chinese and assess its reliability and validity.
Methods:
A sample of 917 community-dwelling older people, aged ≥60 years, in a Chinese city was included between August 2015 and March 2016. Construct validity was assessed using alternative measures corresponding to the TFI items, including self-rated health status (SRH), unintentional weight loss, walking speed, timed-up-and-go tests (TUGT), making telephone calls, grip strength, exhaustion, Short Portable Mental Status Questionnaire (SPMSQ), Geriatric Depression scale (GDS-15), emotional role, Adaptability Partnership Growth Affection and Resolve scale (APGAR) and Social Support Rating Scale (SSRS). Fried's phenotype and frailty index were measured to evaluate criterion validity. Adverse health outcomes (ADL and IADL disability, healthcare utilization, GDS-15, SSRS) were used to assess predictive (concurrent) validity.
Results:
The internal consistency reliability was good (Cronbach's α=0.71). The test-retest reliability was strong (r=0.88). Kappa coefficients showed agreements between the TFI items and corresponding alternative measures. Alternative measures correlated as expected with the three domains of TFI, with an exclusion that alternative psychological measures had similar correlations with psychological and physical domains of the TFI. The Chinese TFI had excellent criterion validity with the AUCs regarding physical phenotype and frailty index of 0.87 and 0.86, respectively. The predictive (concurrent) validities of the adverse health outcomes and healthcare utilization were acceptable (AUCs: 0.65-0.83).
Conclusions:
The Chinese TFI has good validity and reliability as an integral instrument to measure frailty of older people living in the community in China.
... The ageing process accompanies physiological changes such as a loss of bone and muscle mass [5], and frailty may be an outcome of these changes [6,7]. People with frailty are less capable to perform Activities of Daily Living (ADLs), which refer to daily self-care activities such as bathing, toileting, and dressing necessary for a normal life [8]. ADLs are necessary for happiness and quality of life [9]. ...
... Hence, interventions enabling ageing people to avoid the early onset of frailty are necessary. We define frailty as the limitations and impairments in physical performance including Instrumental Activities of Daily Living (IADLs) [8,10]. Though several definitions of frailty exist, we chose this definition as it is suited for our measurement of frailty in the context of geriatric medicine [8]. ...
... We define frailty as the limitations and impairments in physical performance including Instrumental Activities of Daily Living (IADLs) [8,10]. Though several definitions of frailty exist, we chose this definition as it is suited for our measurement of frailty in the context of geriatric medicine [8]. Measuring frailty and functional difficulty in this context enabled us to reach evidence with clinical implications. ...
Background
Research to date suggests that frailty is higher in women and is associated with functional difficulty. This study builds on the evidence by examining the association between frailty and functional difficulty between low- and higher-income groups and between older men and women in these income groups.
Methods
This study adopted a cross-sectional design that complied with the STROBE checklist and included steps against confounding and common methods bias. The population was community-dwelling older adults aged 50 years or older in two urban neighbourhoods in Accra, Ghana. Participants were either in the low-income group in a low socioeconomic neighbourhood (n = 704) or the higher-income group in a high socioeconomic neighbourhood (n = 510). The minimum sample necessary was calculated, and the hierarchical linear regression analysis was utilised to analyse the data.
Results
Frailty was positively associated with functional difficulty in the low- and higher-income samples, but this association was stronger in the higher-income sample. Frailty was positively associated with frailty in men and women within the low- and higher-income samples.
Conclusion
The association of frailty with functional difficulty was consistent between low- and higher-income samples, although the strength of the relationship differed between these samples. In both income samples, the foregoing relationship was consistent between men and women, although the strength of the relationship differed between men and women.
... Multidimensional Frailty was assessed via the Chinese version of the TFI (Dong et al. 2017). The TFI includes 15 items that assess frailty across three domains: physical, psychological, and social. ...
... A total score of five or higher indicates the presence of multidimensional frailty. The Chinese version of the TFI has been shown to have good internal consistency (Cronbach's α = 0.71) (Dong et al. 2017). The Cronbach's alpha coefficient of the TFI was 0.84 in our study. ...
Background
Symptom networks offer a new approach to explore the relationships among various symptoms and provide information for optimising precise symptom management strategies. However, no previous studies have identified the central symptoms of multidimensional frailty.
Design
A cross‐sectional study was conducted from December 2023 to March 2024 in China.
Settings and Participants
A total of 933 community‐dwelling older adults (aged 60 years or older) in China were recruited via convenience sampling.
Methods
Sociodemographic variables, clinical variables and scores on the Tilburg Frailty Indicator were assessed in all participants. The qgraph package and IsingFit package of R software were applied to construct the symptom network. Three node centrality indices (strength, betweenness and closeness) and the expected influence were calculated to identify the central symptoms of the multidimensional frailty network. All statistical analyses were performed in R.
Results
A total of 933 individuals were surveyed in this study, including 472 (50.6%) females. The median age of all participants was 71.0 years. A total of 408 subjects were assessed as multidimensional frailty. The prevalence of multidimensional frailty was 43.7%. The centrality indices revealed that ‘difficulty in walking’, ‘difficulty in maintaining balance’, and ‘feeling down’ were the symptoms with the largest strength and expected influence values.
Conclusion
This study primarily utilised network analysis to construct a symptom network of multidimensional frailty among community‐dwelling older adults. The findings revealed that difficulty in walking, difficulty in maintaining balance, and feeling down were the most central symptoms.
Implications
This study identified the central symptoms of multidimensional frailty in older adults, which may serve as primary intervention targets. Nursing staff could incorporate targeted physical and psychological interventions into person‐centred care plans.
Reporting Methods
This study was reported in accordance with the STROBE guidelines.
Patient or Public Contribution
No patient or public contribution was involved in this study.
... Frailty in a clinical context is limitations and impairments in physical performance including Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs) [5,6]. ADLs are daily self-care activities such as toileting, bathing, and eating whereas IADLs are more complex activities (e.g., vising a grocery shop) by which individuals live in their communities [7]. ...
... Frailty was measured with the 15-item Tilburg Frailty Index and its two descriptive anchors (i.e., 0 -no, and 1 -yes) from previous research [5]. This scale was preferred to others because it measures frailty in a clinical context, is relatively short, and is more suited for older adults. ...
Background
Many studies have highlighted the association between frailty, physical activity behaviour (PAB), and well-being, but no study has investigated a potential moderated mediating role of functional difficulty in this relationship. This association may not be the same between different income levels. This study, therefore, assessed the above moderated mediation between low- and higher-income samples.
Methods
This research employed a cross-sectional design in accordance with established research-reporting guidelines. The study population comprised two distinct Ghanaian samples, with N = 942 individuals in the low-income group and N = 600 individuals in the higher income group. Data analysis was carried out using Hayes's Process model through structural equation modelling, with additional sensitivity analyses performed through hierarchical linear regression.
Results
Frailty had a direct negative effect and an indirect negative effect (through functional difficulty) on well-being in both samples. A partial mediation of functional difficulty was found in the relationship between frailty and well-being in both samples. We also found evidence of a moderated mediation by functional difficulty in both samples; however, this effect was stronger in the higher-income sample.
Conclusion
Older employees with frailty are less likely to report lower functional difficulty and well-being at higher PAB. Our results suggest a need for workplace programmes aimed at encouraging PAB. It also reinforces the importance of individuals performing and maintaining PAB.
... Frailty was assessed using the Chinese version of the Tilburg Frailty Indicator (TFI) developed by Dong et al [32] to assess frailty in older adults. The TFI includes 15 items under 3 dimensions: physical frailty, psychological frailty, and social frailty. ...
... The Chinese version of TFI is a valuable tool for assessing the frailty of older Chinese community residents, with good validity and reliability (Cronbach α = 0.71). [32] 2.2.3. Heart Failure Specific Health Literacy Scale. ...
Chronic heart failure (CHF) is a significant global health challenge, and frailty is common among CHF patients. Although abundant evidence has revealed significant intercorrelations among health literacy, social support, self-management, and frailty, no study has explored their associations into 1 model based on a theoretical framework. The study aimed to test the Information-Motivation-Behavioral Skills Model in a sample of Chinese CHF patients and explore the potential relationships among social support, health literacy, self-management, and frailty. A cross-sectional study was conducted on CHF patients (n = 219) at a tertiary hospital in China. The Tilburg Frailty Indicator, Heart Failure Specific Health Literacy Scale, Social Support Rating Scale, and Self-management Scale of Heart Failure Patients were used to assess frailty, health literacy, social support, and self-management, respectively. Structural equation modeling with the bootstrapping method was used to test the hypothesized relationships among the variables. The results showed that 47.9% of the CHF patients suffered from frailty. Frailty was negatively correlated with health literacy ( r = −0.268, P < .01) with a moderate effect size, social support ( r = −0.537, P < .01) with a large effect size, and self-management ( r = −0.416, P < .01) with a moderate effect size. The structural equation modeling model showed that social support was positively associated with health literacy ( β = 0.419, P < .01) and self-management ( β = 0.167, P < .01) while negatively associated with frailty ( β = −0.494, P < .01). Health literacy was positively associated with self-management ( β = 0.565, P < .01), and self-management was negatively associated with frailty ( β = −0.272, P < .01). Our study suggests the potential positive impacts of health literacy, social support, and self-management on improving frailty in CHF patients. Healthcare providers should strengthen patient health education, improve their health literacy, enhance their social support, and promote their self-management so as to reverse frailty and reduce the risk of adverse outcomes.
... The TFI, developed in the Netherlands in 2010, is a multidimensional screening tool for frailty encompassing physical, psychological, and social aspects. 20 The TFI assigns one point for the presence of each item and zero points for its absence, with a score of five or more indicating frailty. 19 Currently, TFI has been widely used to assess frailty in older populations in Brazil, Denmark, and other countries due to its good reliability and validity. ...
... The study found that the Chinese version of the TFI has good internal consistency reliability (Cronbach's α = 0.71), test-retest reliability (r = 0.88), and criterion validity (with FFP and FI as calibration standards, the AUC of TFI are 0.87 and 0.86 respectively). 20 TFI is a self-reported comprehensive assessment scale that is similar in structure to the GFI, with the advantages of flexible testing and easy scoring. The above studies demonstrated that the TFI was highly reliable after being adapted for use in China, indicating its accuracy for screening early frailty in older individuals residing in both community and nursing home settings. ...
Global aging is rapidly accelerating, which significantly influences the health systems worldwide. Frailty emerges as the most conspicuous hallmark of aging, imposing novel global health challenges. Characterized by a multifaceted decline across physiological system, frailty diminishes an individual’s capacity to maintain equilibrium in the presence of stressors, which leads to adverse outcomes such as falls, delirium, and disability. Several screening tools and interventions have been developed to mitigate the harm caused by frailty to human health, but research on frailty in mainland China commences belatedly with scant studies conducted. Therefore, it is imperative to explore screening methods and treatment modalities tailored to the Chinese context, thereby enhancing the older adults’ quality of life and advancing social medicine. This review aims to elucidate the evolution, diagnosis, and management of frailty, alongside the challenges it poses, with the overarching goal of guiding future diagnostic and therapeutic endeavors. Specifically, we summarized the mechanisms of frailty and intervention strategies in elderly people, and meanwhile, we evaluated the advantages and disadvantages of different measurement tools.
... Frailty is physical impairments and limitations of daily physical activities, including Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs) [1,2]. Though several definitions exist, we adopt this definition because it agrees with our measurement of frailty in a clinical context to proffer implications for health service delivery. ...
... Frailty was measured with the 15-item Tilburg Frailty Index that was borrowed in whole from the literature [1]. It accompanies two descriptive anchors (i.e., no -0, and yes -1) and measures frailty in a clinical context. ...
Background
Research suggests that frailty is associated with lower physical activity and well-being in old age, but social activities at work may facilitate physical activity and its positive effect on well-being among older employees with frailty. This study, therefore, ascertained whether there is a moderated mediation of the association of frailty, Workplace Social Activity (WSA), and well-being by Physical Activity (PA).
Methods
The study adopted a cross-sectional design with relevant sensitivity analyses for confounding. The participants were within two Ghanaian samples with different income levels (low-income, n = 897, and higher income, n = 530). The minimum samples were calculated, and the statistical models were tested with Haye’s Process Model through structural equation modelling.
Results
Frailty was negatively associated with PA, and this relationship was moderated by WSA in both samples. Higher frailty was directly and indirectly associated with lower well-being in the higher-income sample but only indirectly associated with lower well-being in the low-income sample. The mediation of PA in the frailty-well-being relationship is partial in the higher-income sample but complete in the low-income sample. There was evidence of moderated mediation in both samples.
Conclusion
WSA may reduce the strength of the negative association of frailty with PA and well-being among older employees in both samples. Workplace interventions aimed at enhancing WSA may encourage PA and enhance well-being among older employees with frailty.
... Frailty assessment in this study was conducted using the Chinese version of the Tilburg Frailty Indicators (TFI) [26]. The TFI is a self-assessment scale that encompasses a comprehensive multidimensional model [27]. ...
... A score of 5 or higher indicates "frailty", with higher scores indicating greater frailty, while participants scoring below 5 are considered "non-frail". The TFI scale demonstrated good internal reliability with a Cronbach's alpha coefficient of 0.71 and strong retest reliability (r = 0.88) [26]. ...
Background
Frailty is a significant concern among hospitalized older adults, influenced by multiple factors. Understanding the complex interactions between these variables can be facilitated through a network perspective.
Aim
This study aimed to identify the core factor and physiological indicator of frailty in hospitalized elderly patients and visualize their interactions within the network structure.
Methods
Frailty was assessed using the Tilburg Frailty Indicators, with a score of 5 or higher indicating frailty. Additional variables related to sociodemographic, physical and clinical, psychological and cognitive aspects, as well as physiological indicators, were extracted from electronic health records. A partial correlation network analysis was conducted using an adaptive LASSO algorithm, based on univariate correlation and logistic regression, to examine the network structure and identify influential nodes.
Results
The average age of participants was 70.74 ± 7.52 years, with 24.27% classified as frail. Frailty was associated with 38 of 145 initially included variables (P < 0.05). The network analysis revealed depression as the most central node, followed by drugs used, sleep disorders, loneliness, masticatory obstacles, drinking, and number of teeth missing. Hemoglobin emerged as the most central biochemical indicator in the network, based on network center index analysis (Strength = 4.858, Betweenness = 223, Closeness = 0.034).
Conclusions
Frailty in hospitalized older adults is influenced by various social, physical, and psychological factors, with depression as the core factor of utmost importance. Changes in hemoglobin levels could serve as an essential indicator. This innovative network approach provides insights into the multidimensional structure and relationships in real-world settings.
... Appendix A in S1 Appendix shows questions and items used to measure sedentary behaviour. Frailty was measured with the 15-item Tilburg Clinical Frailty Index (see Appendix B in S1 Appendix) with two descriptive anchors (yes-1; no-0) adopted in whole from a previous study [26]. As noted earlier, we used this clinical measure of frailty to be able to identify implications for clinical or geriatric practice. ...
... It adds that disengagement with society is the consequence of factors including a gradual decline in physical functional ability. Frailty is the consequence of a decline in physical function [26,33], which means that higher sedentary behaviour may be associated with frailty. Some previous studies [11,32,33] have explained the positive relationship between frailty and sedentary behaviour with a similar line of argument. ...
Background
Research shows that frailty is associated with higher sedentary behaviour, but the evidence to date regarding this association is inconclusive. This study assessed whether the above association is moderated or modified by gender and age, with sedentary behaviour measured with a more inclusive method.
Methods
This study adopted a STROBE-compliant cross-sectional design with sensitivity analyses and measures against common methods bias. The participants were community-dwelling older adults (mean age = 66 years) in two Ghanaian towns. A self-reported questionnaire was used to collect data from 1005 participants after the minimum sample size necessary was calculated. The hierarchical linear regression analysis was used to analyse the data.
Results
After adjusting for the ultimate confounders, frailty was associated with higher sedentary behaviour (β = 0.14; t = 2.93; p <0.05) as well as partial and absolute sedentary behaviour. Gender modified the above associations in the sense that frailty was more strongly associated with sedentary behaviour among women, compared with men. Age also modified the association between frailty and sedentary behaviour, which suggests that frailty was more strongly associated with higher sedentary behaviour at a higher age.
Conclusion
Sedentary behaviour could be higher at higher frailty among older adults. Frailty is more strongly associated with sedentary behaviour at a higher age and among women, compared with men.
... Gobbens and Uchmanowicz (2021) found that Cronbach's alpha of the TFI was between 0.66 and 0.80. Furthermore, other researchers reported Cronbach's alpha of frailty physical, psychological and So, ranging between 0.57 and 0.79 (Mulasso et al., 2016;Santiago et al., 2018), 0.37 and 0.63 (Gobbens et al., 2010;Uchmanowicz et al., 2016), and 0.25 and 0.59 (Dong et al., 2017;Uchmanowicz et al., 2016). We found that Cronbach's alpha for physical TA B L E 4 Pearson's correlation itemtotal correlation coefficients differences between older people living in nursing homes and community dwelling of the Tilburg Frailty Indicator in Slovenia (TFI-SI) questionnaire. ...
... In our study, the prevalence of frailty was 45% among older people >65 years old living in nursing homes and community dwelling, which is comparable with the studies which involved older people aged 60 years or more residing in community dwelling in Brazil (44.2%) (Santiago et al., 2018), but not with the results from China (17.2%) (Dong et al., 2017) and UK (14%) (Gale et al., 2015). One meta-analysis (O'Caoimh et al., 2021) found that the prevalence in older people living in the community was 12% and 45%, and an overall estimate for pre-frailty was 46% (45%-48%). ...
Aim
The aim of this was to psychometrically adapt and evaluate the Tilburg Frailty Indicator to assess frailty among older people living in Slovenia's community and nursing home settings.
Design
A cross‐cultural adaptation and validation of instruments throughout the cross‐sectional study.
Methods
Older people living in the community and nursing homes throughout Slovenia were recruited between March and August 2021. Among 831 participants were 330 people living in nursing homes and 501 people living in the community, and all were older than 65 years.
Results
All items were translated into the Slovene language, and a slight cultural adjustment was made to improve the clarity of the meaning of all items. The average scale validity index of the scale was rated as good, which indicates satisfactory content validity. Cronbach's α was acceptable for the total items and subitems.
Conclusions
The Slovenian questionnaire version demonstrated adequate internal consistency, reliability, and construct and criterion validity. The questionnaire is suitable for investigating frailty in nursing homes, community dwelling and other settings where older people live.
Impact
The Slovenian questionnaire version can be used to measure and evaluate frailty among older adults. We have found that careful translation and adaptation processes have maintained the instrument's strong reliability and validity for use in a new cultural context. The instrument can foster international collaboration to identify and manage frailty among older people in nursing homes and community‐dwelling homes.
Reporting Method
The Strengthening the Reporting of Observational Studies in Epidemiology checklist for reporting cross‐sectional studies was used.
No Patient or Public Contribution
No patient or public involvement in the design or conduct of the study. Head nurses from nursing homes and community nurses helped recruit older adults. Older adults only contributed to the data collection and were collected from nursing homes and community dwelling.
... Item 13 was not included in the analysis since there was no alternative measure. The alternative measures for the physical frailty domain were: the International Physical Activity Questionnaire-Short Form (IPAQ-SF), measurement of body mass index (BMI), walking speed and balance test from the Short Physical Performance Battery (SPPB), questions on hearing and sight (able to make telephone calls with or without aid/able to read a text with or without aid) used in the validation study of the Chinese TFI), grip strength (measured with a handheld dynamometer) and a statement on exhaustion from the Center for Epidemiologic Studies Depression Scale (CES-D)-I felt that everything I did was an effort [22,24,[28][29][30][31]. For the psychological domain, the measures were the Montreal Cognitive Assessment (MoCA), the Hospital Anxiety and Depression Scale (HADS) and the Pearlin Mastery Scale (PMS) [32][33][34]. ...
... Internal consistency results (KR-20 0.69 and McDonald's ω 0.72) were close to findings in earlier studies (Dutch 0.73, Portuguese 0.78, German 0.67, Brazilian 0.78, and Polish 0.74) [9,[41][42][43][44]. The low internal consistency of the psychological and social domains was expected and has, in earlier studies, been accepted as a reflection of the low number of items for these domains (4 and 3, respectively) [9,30]. We noticed that in our study, the internal consistency of the physical domain was lower than in previous studies; the reason for this remains unclear. ...
The Tilburg Frailty Indicator (TFI) is a questionnaire with 15 questions designed for screening for frailty in community-dwelling older people. TFI has a multidimensional approach to frailty, including physical, psychological, and social dimensions. The aim of this study was to translate TFI into Swedish and study its psychometric properties in community-dwelling older people with multimorbidity. A cross-sectional study of individuals 75 years and older, with ≥3 diagnoses of the ICD-10 and ≥3 visits to the Emergency Department in the past 18 months. International guidelines for back-translation were followed. Psychometric properties of the TFI were examined by determining the reliability (inter-item correlations, internal consistency, test–retest) and validity (concurrent, construct, structural). A total of 315 participants (57.8% women) were included, and the mean age was 83.3 years. The reliability coefficient KR-20 was 0.69 for the total sum. A total of 39 individuals were re-tested, and the weighted kappa was 0.7. TFI correlated moderately with other frailty measures. The individual items correlated with alternative measures mostly as expected. In the confirmatory factor analysis (CFA), a three-factor model fitted the data better than a one-factor model. We found evidence for adequate reliability and validity of the Swedish TFI and potential for improvements.
... The total score of the scale is the sum of the scores of each item, with a range of 0-15 points, and ≥ 5 points are frailty, and the higher the score, the more severe the frailty. The TFI scale has been validated by domestic scholars, showing good reliability and validity (29). In this study, the Cronbach's α coefficient was 0.830. ...
Introduction
Frailty is prevalent among preoperative gastric cancer (GC) patients and significantly affects surgical risk and long-term recovery. Family health may hold substantial potential for mitigating frailty, although the mechanisms underlying this effect remain unclear. This study aims to investigate the impact of family health on frailty in preoperative GC patients, and the mediating effects of health literacy and physical activity.
Methods
A total of 240 patients scheduled for radical gastrectomy at a tertiary hospital in China were surveyed using Family Health Scale (FHS), Health Literacy Scale (HLS-SF), International Physical Activity Questionnaire (IPAQ-7), and Tilburg Frailty Indicator (TFI). Data were analyzed using independent t-tests, χ² tests, Pearson’s correlation, and binary logistic regression. Mediation analysis with Structural Equation Modeling (SEM) was then applied to explore the relationships between variables.
Results
Family health in preoperative GC patients was negatively correlated with frailty (r = −0.791, p < 0.01) and positively correlated with both health literacy (r = 0.806, p < 0.01) and physical activity (r = 0.464, p < 0.01). Mediating effect analysis indicated that the direct effect of family health on frailty was −0.837, while health literacy and physical activity served as partial mediators in this relationship, with indirect effects of −0.332 and −0.095 (both p < 0.01), respectively. The mediating effects accounted for 33.83% of the total effect.
Conclusion
Family health directly affects frailty and also exerts an indirect impact through the mediators of health literacy and physical activity. These findings suggest that healthcare professionals should focus on vulnerable populations with low family health and implement family-centered preoperative frailty interventions. Guiding GC patients to improve health literacy and engage in personalized family-based exercises can help delay or reverse preoperative frailty, promoting long-term recovery outcomes.
... The higher the score, the more severe the weakness. The Cronbach's α of its Chinese version is 0.73 (Dong et al. 2017) and in the current study was 0.68. ...
Aims
To investigate the status of social isolation among middle‐aged and elderly breast cancer patients and identify its influencing factors. Additionally, to explore the mediating role of self‐perception of aging between frailty and social isolation, as well as the moderating effect of menopausal symptoms.
Design
A cross‐sectional study guided by the Strengthening the Reporting of Observational Studies in Epidemiology.
Methods
This study was conducted on middle‐aged and elderly breast cancer patients from September 2022 to February 2023 in Guangzhou, China. Related data were assessed by structural questionnaires. Correlation analysis and regression analysis were performed by SPSS 26.0 while PROCESS macro v4.0 was used to test the moderated mediation model.
Results
Breast cancer patients aged 45–82 years experienced moderate social isolation. It was influenced by educational level, residence, menopause symptoms, self‐perception of aging, and frailty. The moderated mediation model involving self‐perception of aging and menopausal symptoms for explaining how frailty causes social isolation was supported. The mediating role of self‐perception of aging gradually strengthens as menopausal symptoms become severe.
Conclusion
Social isolation resulting from frailty in middle‐aged and elderly breast cancer patients is mediated by self‐perception of aging, with menopausal symptoms amplifying this effect. Interventions focused on improving self‐perception of aging and managing menopausal symptoms may help reduce social isolation by mitigating the impact of frailty.
Impact
This study highlights the importance of addressing frailty, self‐perception of aging, and menopausal symptoms in clinical nursing practice, which may help reduce social isolation among breast cancer patients.
Patient or Public Contribution
Patients contributed by completing the questionnaire, ensuring the accuracy and completeness of the information with assistance from the research team.
... A score > 5 indicates frailty (Gobbens et al., 2010b). The TFI has been validated among older Chinese adults (Dong et al., 2017;Si et al., 2021). This study followed the TFI based on 14 relevant variables derived from Wave 4. The variable related to weight was not applied owing to data unavailability (Supplementary Table S2). ...
Objective
Psychological frailty, an emerging concept, lacks a standardized definition, measuring instrument, and empirical evidence in Asian (especially Chinese) populations. An effective instrument to measure psychological frailty should be urgently developed. Therefore, this study aimed to develop and initially validate a Psychological Frailty Index (PFI) based on the China Health and Retirement Longitudinal Study (CHARLS). The study assessed the applicability of the PFI to adverse health outcomes as a secondary aim.
Results
Factor analysis of the 15-item PFI extracted four factors of psychological frailty (psychological distress, cognitive decline, physical vulnerability, and memory decline). The PFI demonstrated satisfactory internal consistency (Cronbach’s alpha = 0.764) and criterion validity (rho = 0.806). Psychological frailty was significantly associated with lower life expectancy (odds ratio [OR] 1.98, 95% confidence interval [CI] 1.71–2.29), higher outpatient treatments (1.25, 1.03–1.51), and increased hospitalization (1.45, 1.22–1.74).
Conclusion
The PFI could be a reliable instrument for identifying psychological frailty. The PFI is a novel tool that measures health indicators of older adults at risk of increased psychological vulnerability, but it requires further validation.
... This instrument showed acceptable validity and reliability, establishing an optimal cut-off point (Zhao et al., 2020;Dong et al., 2017a;Kajsa et al., 2016;Alqahtani & Nasser, 2019;Alqahtani et al., 2020). For its part, the TFI was validated as an effective resource for clinical frailty screening in various primary care settings (Dong et al., 2017;Dong et al., 2018). ...
This study is a systematic review addressing cognitive frailty, measurement instruments, and their impact on comprehensive care for older adults between 2013 and 2023. It seeks to identify findings on the distribution of studies in relation to year, country of publication, and methodology employed, as well as the instruments available to measure cognitive frailty and the scientific evidence supporting its assessment in midlife. We included studies published between 2013 and 2023 that addressed the topic of cognitive frailty and measurement instruments in midlife, excluding papers that did not provide primary data. A systematic search was performed in Scopus, PubMed, Web of Science, and Science Direct databases. The risk of bias was assessed using the Cochrane tool. Twenty-one studies were identified, of which three presented new instruments for measuring cognitive frailty, eleven focused on the validation and comparison of psychometric properties, and seven examined the assessment of frailty in midlife. Research on instruments for measuring cognitive frailty has grown in the last five years, concentrating on high- and upper-middle-income countries, with a quantitative and cross-sectional methodological approach. Validation and cross-cultural adaptation of scales such as FRAIL and the Tilburg Frailty Indicator predominate, demonstrating efficacy and validity in community settings. Only three studies validate Frailty Indices using longitudinal data in middle-aged population. The review highlights the efficacy and validity of existing instruments, as well as the growth in cognitive frailty research. Strengths include growing research and instrument validation; however, it is limited to high- and upper-middle-income countries. The review suggests increased attention to cognitive frailty, with new instruments incorporating cognitive components, which could improve assessment in midlife.
... Frailty was assessed with the Tilburg frailty i indicator (TFI). Te TFI was originally compiled by Gobbens [19], and the Chinese version was translated by Dong et al. [20]. Te Chinese TFI contains 15 items addressing three domains, including physical, psychological, and social aspects. ...
Objective. The number of cancer survivors is increasing, and the high prevalence of frailty not only reduces quality of life but also affects the treatment of cancer patients. This study aimed to identify the prevalence and risk factors of frailty in cancer patients and to construct a nomogram to predict the probability of frailty. Methods. Nine hundred fifty-eight cancer patients were included in this retrospective study, randomly divided into a development set (n = 680) and a validation set (n = 278). Frailty was assessed using the Tilburg frailty indicator (TFI). Social support, medical coping styles, and psychological distress were assessed by the Social Support Self-Rating Scale (SSRS), Medical Coping Modes Questionnaire (MCMQ), and distress thermometer (DT), respectively. Results. The prevalence of frailty in cancer patients was 45.93%. Cancer patients who exercised regularly, ate a balanced diet, and actively coped with diseases were less likely to become frail. The risk factors for frailty identified by a multivariate analysis were parenteral nutrition, advanced TNM staging, vegetarian diet, unemployment, psychological distress ≥4, low physical activity, and negative coping styles. These risk factors were used to construct a nomogram, and the C-index, calibration curve, and decision curve analysis (DCA) were used to assess the performance of the nomogram. The C-index was 0.762, and the calibration curve showed satisfactory coherence. The net benefit of the nomogram was better between threshold probabilities of 17%–96% in DCA. Conclusion. Special focus needs to be placed on frail cancer patients due to their high prevalence and severe outcomes. Clinical medical workers could use this nomogram to identify high-risk patients and intervene early to prevent frailty.
... The impact score index was employed for face validity and 1.5 was considered as cut off point. Related to content validity, content validity index (CVI) and content validity ratio (CVR) were calculated [47]. Further, 0.79 was regarded as threshold for CVI and lawashe table was used for comparing obtained CVR value considering the experts numbers (in the present study, the 10 experts and 0.62 considering as threshold limit). ...
Background
Frailty is identified as the primary goal of preventing the various consequences. The present study aimed to assess validity and reliability of the Persian adapted version of the Tilburg frailty indicator (TFI) in Iran.
Method
This cross-sectional study included three phases of translating the indicator to Persian, assessing the face and content validity, completing the P-TFI by older people, who helped assess the reliability and construct validity. For construct validity, convergent and divergent validity were used. It was expected that the TFI domain scores would show the highest correlations with their related measures of frailty (convergent construct validity) and the lowest correlations with measures of the other domains (divergent construct validity). The study population consisted of 400 older people, selected from six health care centers.
Results
The mean age of the participants was 69.05 ± 7.28 years and the majority of the participants were married woman with less than a high school education. The total mean score of TFI was 8.26 ± 1.80, and 42.75% was classified as frail. The test-retest reliability was 0.88 for the total scale, 0.80 for physical, 0.65 for psychological, and 0.81 for social domains. The mean score of frailty and its dimensions (physical, psychological, and social) varied from 4.35 ± 1.78, 1.81 ± 1.33, 1.69 ± 0.73, and 0.86 ± 0.61, respectively. The total score of the TFI was correlated with each alternative measure and the convergent validity was proved. Further, the kappa values ranging from 535 to 0.967 were significant and test- retest reliability for total, physical, psychological, and social dimension were 0.88, 080, 065, and 081, respectively. Further, the convergent or divergent validity is being discussed for clarity.
Conclusion
The Persian version of the TFI is valid and easy scored tools among Iranian’s older people.
... Frailty was assessed using the Chinese version of the TFI. The reliability and validity of the Chinese TFI scale were good, the overall Cronbach's α was 0.71, and the auc was 0.87 (Dong et al., 2017). In this study, the Cronbach's α was 0.836. ...
Objectives
To investigate the frailty status of inpatients with chronic heart failure (CHF) and analyse its influencing factors, so as to provide evidence for the early identification of high‐risk groups and frailty management.
Background
Early identification of frailty can guide the development and implementation of holistic and individualized treatment plans. However, at present, the frailty of patients with CHF has not attracted enough attention.
Design
A cross‐sectional study.
Methods
From June 2022 to June 2023, a convenience sample of 256 participants were recruited at a hospital in China. Multivariate logistic regression analysis was used to explore the influencing factors of frailty in patients with CHF, and an ROC curve was drawn to determine the cut‐off values for each influencing factor. STROBE checklist guides the reporting of the manuscript.
Results
A total of 270 questionnaires were sent out during the survey, and 256 valid questionnaires were ultimately recovered, resulting in an effective recovery rate of 94.8%. The incidence of frailty in hospitalized patients with CHF was 68.75%. Multivariable logistic regression analysis showed that age, self‐care ability, nutritional risk, Kinesiophobia and NT‐proBNP were risk factors for frailty, while albumin and LVEF were protective factors.
Conclusion
Multidimensional frailty was prevalent in hospitalized patients with CHF. Medical staff should take measures as early as possible from the aspects of exercise, nutrition, psychology and disease to delay the occurrence and development of frailty and reduce the occurrence of clinical adverse events caused by frailty.
Relevance to Clinical Practice
This study emphasizes the importance of the early identification of multidimensional frailty and measures can be taken to delay the occurrence and development of frailty through exercise, nutrition, psychology and disease treatment.
Patient or Public Contribution
Patients contributed through sharing their information required for the case report form and filling out questionnaires.
... In recent years, a Chinese self-reported frailty screening questionnaire (FSQ) based on modified Fried FP criteria was developed and validated in different settings (35). A Chinese version of the TFI was also developed to measure frailty among community-dwelling older adults (36). A 10-item Chinese frailty screening scale (CFSS-10) (17) was successfully developed and validated. ...
As the aging population increases globally, health-related issues caused by frailty are gradually coming to light and have become a global health priority. Frailty leads to a significantly increased risk of falls, incapacitation, and death. Early screening leads to better prevention and management of frailty, increasing the possibility of reversing it. Developing assessment tools by incorporating disease states of older adults using effective interventions has become the most effective approach for preventing and controlling frailty. The most direct and effective tool for evaluating debilitating conditions is a frailty screening tool, but because there is no globally recognized gold standard, every country has its own scale for national use. The diversity and usefulness of the frailty screening tool has become a hot topic worldwide. In this article, we reviewed the frailty screening tool published worldwide from January 2001 to June 2023. We focused on several commonly used frailty screening tools. A systematic search was conducted using PubMed database, and the commonly used frailty screening tools were found to be translated and validated in many countries. Disease-specific scales were also selected to fit the disease. Each of the current frailty screening tools are used in different clinical situations, and therefore, the clinical practice applications of these frailty screening tools are summarized graphically to provide the most intuitive screening and reference for clinical practitioners. The frailty screening tools were categorized as (ⅰ) Global Frailty Screening Tools in Common; (ⅱ) Frailty Screening Tools in various countries; (ⅲ) Frailty Screening Tools for various diseases. As science and technology continue to advance, electronic frailty assessment tools have been developed and utilized. In the context of Coronavirus disease 2019 (COVID-19), electronic frailty assessment tools played an important role. This review compares the currently used frailty screenings tools, with a view to enable quick selection of the appropriate scale. However, further improvement and justification of each tool is needed to guide clinical practitioners to make better decisions.
... Frailty of older gastric cancer survivors at discharge, 1, 3, 6, and 12 months after surgery was assessed using the Tilburg Frailty Indicator (TFI) during telephone follow-up by trained investigators. This scale was compiled by Gobbens et al. [13] in 2010 and has been modified and verified in China [14]. The scale contains 15 items and the total score of the scale is 0-15 points, and its cut-off value was 5, with a higher score indicating more severe frailty. ...
... Frailty was assessed using the Chinese version of the TFI. its Cronbach's alpha coefficient was 0.846, indicating that the instrument had been proven valid and reliable for assessing multidimensional frailty in Chinese community-dwelling older people (Dong et al., 2017). It is a self-rating questionnaire designed to identify multidimensional frailty. ...
Objectives
The aims of this study were to (i) compare the prevalence of multidimensional frailty in middle‐aged and older people with stroke and to (ii) explore the relationship between multidimensional frailty and quality of life (QoL) in this patient population.
Background
In recent years, stroke patients have become increasingly younger. As an important risk factor for stroke patients, frailty has gradually drawn research attention because of its multidimensional nature.
Design
This study used a cross‐sectional design.
Methods
The study included 234 stroke patients aged 45 and older. Multidimensional frailty was defined as a holistic condition in which a person experiences losses in one or more domains of human functioning (physical, psychological and social) based on the Tilburg Frailty Indicator, and QoL was based on the short version of the Stroke‐Specific Quality of Life Scale. Hierarchical regression was used to analyse the correlation factors of QoL. STROBE checklist guides the reporting of the manuscript.
Results
A total of 128 (54.7%) participants had multidimensional frailty, 48 (44.5%) were middle aged and 80 (63.5%) were older adults. The overall QoL mean score of the participants was 47.86 ± 9.04. Multidimensional frailty was negatively correlated with QoL. Hierarchical regression analysis showed that multidimensional frailty could independently explain 14.6% of the variation in QoL in stroke patients.
Conclusions
Multidimensional frailty was prevalent in middle‐aged and older people with stroke, and it was a significant factor associated with QoL in stroke patients.
Relevance to Clinical Practice
This study emphasises the importance of the early identification of multidimensional frailty. And targeted interventions should be studied to prevent the occurrence of multidimensional frailty and thereby improve the QoL of patients.
Patient or Public Contribution/s
There are no patient or public contributions to this study.
... Many studies have demonstrated that the TFI has good psychometric properties for assessing frailty among communitydwelling older people in the Netherlands (Gobbens et al., 2020; Gobbens, van Assen et al., 2010bvan Assen et al., , 2012a and other countries e.g. China (Dong et al., 2017), Brazil (Santiago et al., 2013) and Portugal (Coelho et al., 2015). ...
Chronic diseases had the strongest associations with total and physical frailty. • The effects of chronic diseases on frailty differed strongly across diseases. • Urinary incontinence and severe back disorder impaired frailty most. • Cancer and hypertension had the weakest associations with frailty. • Different weight should be given to individual chronic diseases in a measure of multimorbidity. A R T I C L E I N F O Keywords: Chronic diseases Multimorbidity Multidimensional frailty Tilburg frailty indicator A B S T R A C T Objective: To examine the associations between individual chronic diseases and multidimensional frailty comprising physical, psychological, and social frailty. Methods: Dutch individuals (N = 47,768) age ≥ 65 years completed a general health questionnaire sent by the Public Health Services (response rate of 58.5 %), including data concerning self-reported chronic diseases, multidimensional frailty, and sociodemographic characteristics. Multidimensional frailty was assessed with the Tilburg Frailty Indicator (TFI). Total frailty and each frailty domain were regressed onto background characteristics and the six most prevalent chronic diseases: diabetes mellitus, cancer, hypertension, arthrosis, urinary incontinence, and severe back disorder. Multimorbidity was defined as the presence of combinations of these six diseases. Results: The six chronic diseases had medium and strong associations with total ((f 2 = 0.122) and physical frailty (f 2 = 0.170), respectively, and weak associations with psychological (f 2 = 0.023) and social frailty (f 2 = 0.008). The effects of the six diseases on the frailty variables differed strongly across diseases, with urinary incontinence and severe back disorder impairing frailty most. No synergetic effects were found; the effects of a disease on frailty did not get noteworthy stronger in the presence of another disease. Conclusions: Chronic diseases, in particular urinary incontinence and severe back disorder, were associated with frailty. We thus recommend assigning different weights to individual chronic diseases in a measure of multi-morbidity that aims to examine effects of multimorbidity on multidimensional frailty. Because there were no synergetic effects of chronic diseases, the measure does not need to include interactions between diseases.
... Additional file 1 shows items used to measure sedentary behaviour. Frailty was measured with the standardised 15-item Tilburg Frailty Indicator with a dichotomous descriptive anchor (i.e., no -1, and yes -2) that was adopted in whole from a previous study [21]. This scale is a tool used in clinical practice to measure frailty as general weakness of the body and the condition of being delicate. ...
Background
Living in hilly neighbourhoods can be associated with sedentary behaviour, but no study has compared sedentary behaviour and its associations with frailty, chronic diseases, and poor health between flat and hilly neighbourhoods among older adults. This study, therefore, compared older adults’ sedentary behaviour and its association with frailty, poor health, and chronic disease status between low and hilly neighbourhoods.
Methods
This study utilised a STROBE-compliant cross-sectional design with sensitivity analyses and a common methods bias assessment. The participants were 1,209 people aged 50 ⁺ years who resided in flat (Ablekuma North, n = 704) and hilly (Kwahu East, n = 505) neighbourhoods in Ghana. The data were analysed with the independent samples t -test and hierarchical linear regression.
Results
Older adults in the hilly neighbourhood were more sedentary than those in the flat neighbourhood. The association between sedentary behaviour and chronic disease status was significant in both neighbourhoods, but this relationship was stronger in the hilly neighbourhood. Older adults in the flat neighbourhood reported lower sedentary behaviour at higher frailty (β = -0.18; t = -3.2, p < 0.001), but those in the hilly neighbourhood reported higher sedentary behaviour at higher frailty (β = 0.16; t = 3.54, p < 0.001).
Conclusions
Older adults living in the hilly neighbourhood reported higher sedentary behaviour. In the hilly neighbourhood, sedentary behaviour was more strongly associated with frailty and chronic disease status. Older adults in hilly neighbourhoods may need extra support to avoid sedentary behaviour.
... An individual with a score of ≥5 is considered frailty: higher scores indicate greater degrees of frailty. Previous studies have demonstrated the reliability and validity of the TFI among the Chinese population [31]. In this study, The Cronbach's alpha coe cient for the TFI was 0.735. ...
Background
Falls are associated with an increased risk of frailty in middle-aged and older adults; however, the mediating role between falls and frailty remains unclear. The primary objective of this study is to examine the relationship between falls and frailty in middle-aged and elderly individuals residing in Yunnan Province, China, with a specific emphasis on exploring the potential mediating effect of chronic pain across different ethnic groups.
Methods
Employing a cross-sectional design, data collection was conducted from July to December 2022 in five selected counties. Baron and Kenny’s causal steps method was used to explore the mediating effect of chronic pain on the relationship between falls and frailty. Spearman correlation analysis, multiple linear regression models, and bootstrap method were employed for data analysis.
Results
A total of 2,710 respondents participated in this study. The prevalence of falls among middle-aged and older individuals was 12.77%, while the prevalence of frailty in the same population was observed to be 21.62%. Spearman correlation analysis revealed significant positive association between chronic pain and both falls (r=0.135, P<0.05) as well as frailty (r=0.383, P<0.05). Frailty also exhibited a significant positive correlation with falls (r=0.162, P<0.05). After adjusting for all covariates, the total effect of falls on frailty was estimated to be 1.065 (95% bootstrap CI: 0.804~1.326), with a direct effect estimate of 0.797 (95% bootstrap CI: 0.511~1.083). The indirect effect of chronic pain on this association was found to be approximately one-quarter at 0.268 (95% bootstrap CI: 0.170~0.366). The subgroup analysis discovered differences in the mediating effects across different ethnic groups; specifically, the proportions mediated by chronic pain were found to be 28.2%, 18.4%, and 21.5% for Han majority group, Zhiguo ethnic minorities, and other ethnic minority groups, respectively.
Conclusion
This study provides valuable insights into the intricate association between frailty, falls, and chronic pain among middle-aged and older adults from diverse ethnic backgrounds in a western province of China. Effective management strategies targeting chronic pain and falls prevention could serve as crucial interventions to address frailty.
... 4 In the general elderly community, approximately 12% of individuals are frail. 5 However, this percentage is notably higher in patients with cancer, with a median incidence of 42%. 6 For example, newly diagnosed multiple myeloma patients had a frailty incidence of 54%, 7 while those with chronic myeloid leukemia and diffuse large B cell lymphoma had rates of 49.6% and 49%. ...
Objective
This study aimed to develop and validate an assessment tool for predicting and mitigating the risk of frailty in patients diagnosed with hematologic malignancies.
Methods
A total of 342 patients with hematologic malignancies participated in this study, providing data on various demographics, disease-related information, daily activities, nutritional status, psychological well-being, frailty assessments, and laboratory indicators. The participants were randomly divided into training and validation groups at a 7:3 ratio. We employed Lasso regression analysis and cross-validation techniques to identify predictive factors. Subsequently, a nomogram prediction model was developed using multivariable logistic regression analysis. Discrimination ability, accuracy, and clinical utility were assessed through receiver operating characteristic (ROC) curves, C-index, calibration curves, and decision curve analysis (DCA).
Results
Seven predictors, namely disease duration of 6–12 months, disease duration exceeding 12 months, Charlson Comorbidity Index (CCI), prealbumin levels, hemoglobin levels, Generalized Anxiety Disorder-7 (GAD-7) scores, and Patient Health Questionnaire-9 (PHQ-9) scores, were identified as influential factors for frailty through Lasso regression analysis. The area under the ROC curve was 0.893 for the training set and 0.891 for the validation set. The Hosmer-Lemeshow goodness-of-fit test confirmed a good model fit. The C-index values for the training and validation sets were 0.889 and 0.811, respectively. The DCA curve illustrated a higher net benefit when using the nomogram prediction model within patients threshold probabilities ranging from 10% to 98%.
Conclusions
This study has successfully developed and validated an effective nomogram model for predicting frailty in patients diagnosed with hematologic malignancies. The model incorporates disease duration (6–12 months and>12 months), CCI, prealbumin and hemoglobin levels, GAD-7, and PHQ-9 scores as predictive variables.
... Convergent validity of the TFI was con rmed by statistically signi cant kappa coe cient of each TFI item with their related measures. The majority of the TFI items had good and excellent agreement with related frailty measures, but another study showed fair or moderate agreement with alternative frailty measures validity except for cognitive functions, it was moderate and for living arrangement, it was excellent [49]. ...
Background:
Frailty has been identified as the primary goal of the preventing the various s aging consequences in many studies. Considering frailty help us to plan and train properly. valid and reliable tools are needed. The current study aimed to assess validity and reliability of the Persian adapted version of the Tilburg frailty indicator in Iran.
Method:
The current study is cross sectional study included three phases: at first phase, the indicator translated to Persian, at the next step, face and content validity was assessed. During the third phase, the P-TFI was sent out for completion to elderlies, who helped assess reliability and construct validity. For construct validity, convergent and divergent validity were used. It was expected that the TFI domain scores would show the highest correlations with their related measures of frailty (convergent construct validity) and the lowest correlations with measures of the other domains (divergent construct validity). Overall, 400 elderlies entered the study as the study population from six health care centers.
Results
The mean age of the participants was 69.05±7.28 (ranged from 60 to 93) years old. The majority of the participants were female (56.8). More than half of the participants had spouse. The majority had less than twelve years of education (81.5%), and most participants had a modest level of income. an overall of 168 (42%) older people lived with their spouse and child. The mean total score of TFI was 8.26±1.80, and 171 participants (42.75%) were classified frail in terms of the original cut-point of the scale (i.e., the total score ≥5): with the, and considering 6 as the threshold limit for TFI (i.e., The total score ≥6), 89 participants (22.25) were classified as frail. The scores for KR-21 range from 0 to 1, where 0 is no reliability and 1 is perfect reliability. The test-retest reliability for the 14-day interval was 0.88 for the total scale, 0.80 for physical domain, 0.65 for psychological domain and 0.81 for social domain. Mean score of frailty and its dimensions varied from 4.35±1.78, 1.81±1.33,1.69±0.73.0.86±061 for total frailty, physical, psychological and social respectively. The total score of the TFI significantly correlated with each alternate measure as expected. The convergent validity of the TFI was proved by the Cohen’s kappa coefficient between each item of the TFI and corresponding alternate tools. All of the kappa values ranging from.535 to 0.967 were statistically significant.
... 73 The TFI has been validated in various populations and countries, showing good reliability and validity. 21,25,74 The TFI assesses frailty across physical, psychological and social domains. 75,76 This multidimensional approach to frailty contributes to clinical trials studying interventions that target different aspects of frailty. ...
Background:
Frailty is a global health problem, including in African countries. Despite this, no reliable or valid frailty instruments incorporate any African language, and no research exists to cross-culturally adapt and test the validity and reliability of instruments commonly used in other countries for use within African countries. The Tilburg Frailty Indicator (TFI) is a reliable and validated instrument with the potential to be relevant for older populations living in Africa. This study aimed to develop the TFI Amharic (TFI-AM) version for use within Ethiopia.
Methods:
This study employed psychometric testing and the evaluation of a translated and adapted instrument. The original English language version of the TFI was translated and culturally adapted into Amharic using the World Health Organization process of translation and adaptation of an instrument. A convenience sample of ninety-six community-dwelling older people 60 years and over was recruited. Cronbach's alpha was used for the analysis of the internal consistency of the TFI Amharic (TFI-AM) version using IBM SPSS 26.0 (IBM Corp., Armonk, NY, USA). Face and content validities of the TFI-AM were determined.
Results:
The TFI-AM total mean score was 5.76 (±2.89). The internal consistency of the TFI-AM was very good with an overall Cronbach alpha value of 0.82. The physical domain showed the highest reliability with a 0.75 Cronbach's alpha value while the social domain was the lowest with a 0.68 Cronbach's alpha value. The Cronbach's alpha reliability coefficients of the instrument ranged from 0.68 to 0.75. The item content validity index value ranged from 0.83 to 1.0 and the total content validity index average for the instrument was 0.91.
Conclusion:
The TFI-AM is reliable, valid, and reproducible for the assessment of frailty among community-dwelling older populations in Ethiopia. TFI-AM proved an easy-to-administer, applicable and fast instrument for assessing frailty in community-dwelling older populations.
... A possible reason for this disparity is that our study used the cut-off points proposed by the original authors for FP, FRAIL, and TFI, however, these cutoffs may not be sensitive enough to detect small changes in frailty status when applied to the Chinese population, especially given that we observed higher sensitive values when lower cut-offs were applied (Table 3). Previous studies (36,37) on the validation of frailty scales also suggested that for the TFI and FRAIL scales used in Chinese community-dwelling older adults, the optimal cutoff points for frailty were 4 and 2, respectively, which were slighter . /fpubh. . ...
Background
Data on which frailty scales are most suitable for estimating risk in Chinese community populations remain limited. Herein we examined and compared four commonly used frailty scales in predicting adverse outcomes in a large population-based cohort of Chinese older adults.
Methods
A total of 5402 subjects (mean age 66.3 ± 9.6 years, 46.6% male) from the WHO Study on global AGEing and adult health (SAGE) in Shanghai were studied. Frailty was measured using a 35-item frailty index (FI), the frailty phenotype (FP), FRAIL, and Tilburg Frailty Indicator (TFI). Multivariate logistic regression models were performed to evaluate the independent association between frailty and outcomes including 4-year disability, hospitalization, and 4- and 7-year all-cause mortality. The accuracy for predicting these outcomes was determined by evaluating the area under the curve (AUC). The prevalence of frailty, sensitivity, and specificity were calculated using our proposed cut-off points and other different values.
Results
Prevalence of frailty ranged from 4.2% (FRAIL) to 16.9% (FI). FI, FRAIL and TFI were comparably associated with 4-year hospitalization, and 4- and 7-year mortality (adjusted odds ratios [aORs] 1.44–1.69, 1.91–2.22 and 1.85–2.88, respectively). FRAIL conferred the greatest risk of 4-year disability, followed by FI and TFI (aOR 5.55, 3.50, and 1.91, respectively). FP only independently predicted 4- and 7-year mortality (aOR 1.57 and 2.21, respectively). AUC comparisons showed that FI, followed by TFI and FRAIL, exhibited acceptable predictive accuracy for 4-year disability, 4- and 7-year mortality (AUCs 0.76–0.78, 0.71–0.71, 0.65–0.72, respectively), whereas all scales poorly predicted 4-year hospitalization (AUCs 0.53–0.57). For each scale, while specificity estimates (85.3–97.3%) were high and similar across all outcomes, their sensitivity estimates (6.3–56.8%) were not sufficient yet. Prevalence of frailty, sensitivity, and specificity varied considerably when different cut-off points were used.
Conclusion
Frailty defined using any of the four scales was associated with an increased risk of adverse outcomes. Although FI, FRAIL and TFI exhibited fair-to-moderate predictive accuracy and high specificity estimates, their sensitivity estimates were not sufficient yet. Overall, FI performed best in estimating risk, while TFI and FRAIL were additionally useful, the latter perhaps being more applicable to Chinese community-dwelling older adults.
This study was designed to evaluate the postoperative frailty status of patients with non-small cell lung cancer, identify influencing factors, establish a machine learning-based prediction model, and explore the correlation between frailty status at 3 months and early recovery at 1 month postoperatively.
This retrospective analysis included patients with non-small cell lung cancer who underwent surgery at our hospital from 2021 to 2024. Clinical variables, including demographics, tumor characteristics, treatment, and laboratory tests, were analyzed. Feature selection and model construction were performed by using LASSO regression. Cross-validation assessed the accuracy of the models. Frailty at 3 months and quality of recovery at 1 month postoperatively were measured by using the Tilburg Frailty Index and Quality of Recovery (QoR-15) scales, respectively.
A total of 1,013 patients were included. The initial model achieved an AUC of 0.833, accuracy of 0.854, recall of 0.382, and F1 score of 0.502 in the training set, and an AUC of 0.786, accuracy of 0.857, recall of 0.242, and F1 score of 0.364 in the validation set. Of the patients, 190 (18.8%) developed frailty at 3 months postoperatively. After applying Synthetic Minority oversampling Technique to balance the data, the model’s performance improved (area under the curve [AUC] 0.850, accuracy 0.791, recall 0.818, and F1 score 0.795 for the training set; AUC 0.819, accuracy 0.778, recall 0.762, and F1 score 0.781 for the test set). Additionally, we developed a nomogram to visually represent the predictive model, enabling clinicians to easily assess frailty risk in individuals based on key factors. Correlation analyses showed that frailty at 3 months was moderately negatively correlated with early recovery at 1 month (correlation coefficient = − 0.370).
This study developed a predictive model of postsurgical frailty in lung cancer, providing insights into personalized patient management and early recovery improvement. Further studies should explore the clinical application of the model.
Aim
This study aimed to identify the heterogeneous trajectories of frailty and determine the predictors of distinct trajectories in patients with heart failure.
Design
A longitudinal study.
Methods
A total of 253 patients with heart failure were recruited at the cardiology department of a tertiary hospital between February and December 2023. Frailty was assessed at baseline, 1 and 4 months after discharge. Patients' sociodemographic characteristics, physical symptoms, nutritional status, psychological distress, illness perception and social networks were obtained at baseline using a structured questionnaire. Group‐based trajectory modelling was performed to identify the heterogeneity of the trajectories of frailty. Multiple logistic regression and decision tree models were used to explore the predictors of heterogeneous trajectories of frailty.
Results
Three distinct trajectories of frailty were identified in patients with heart failure: low frailty with high‐degree improvement group (46.2%), moderate frailty with high‐degree improvement group (41.1%) and high frailty with low‐degree improvement group (12.6%). Multiple logistic regression analysis showed that physical symptoms, nutritional status, illness perception and employment status were entered as independent predictors of heterogeneous trajectories of frailty. The decision tree model demonstrated that physical symptoms were the primary predictors, followed by nutritional status, illness perception and psychological distress.
Conclusions
Three distinct categories of frailty trajectories were identified in patients with heart failure. Physical symptoms, nutritional status, psychological distress, illness perception and employment status were independent predictors of heterogeneous trajectories of frailty, with physical symptoms being the most important predictor.
Implication to Clinical Practice
Dynamic frailty assessment is recommended. Interventions aimed at alleviating physical symptoms, psychological distress and negative illness perception, and improving nutritional status may be conducive to delaying or reversing frailty in patients with heart failure, particularly in unemployed individuals.
Reporting Method
The reporting followed the STROBE guideline.
Patient or Public Contributions
No patient or public contribution.
Aim
To investigate the risk factors associated with frailty in older patients with ischaemic stroke, develop a nomogram and apply it clinically.
Design
A cross‐sectional study.
Methods
Altogether, 567 patients who experienced ischaemic strokes between March and December 2023 were temporally divided into training ( n = 452) and validation ( n = 115) sets and dichotomised into frail and non‐frail groups using the Tilburg Frailty Indicator scale. In the training set, feature selection was performed using least absolute shrinkage and selection operator regression and random forest recursive feature elimination, followed by nomogram construction using binary logistic regression. Internal validation was performed through bootstrap re‐sampling and the validation set was used to assess model generalisability. The receiver operating characteristic curve, Hosmer–Lemeshow test, Brier score, calibration curve, decision curve analysis and clinical impact curve were used to evaluate nomogram performance.
Results
The prevalence of frailty was 58.6%. Marital status, smoking, history of falls (in the preceding year), physical exercise, polypharmacy, albumin levels, activities of daily living, dysphagia and cognitive impairment were predictors in the nomogram. Receiver operating characteristic curve analysis indicated outstanding discrimination of the nomogram. The Hosmer–Lemeshow test, calibration curve and Brier score results confirmed good model consistency and predictive accuracy. The clinical decision and impact curve demonstrated notable clinical utility. This free, dynamic nomogram, created for interactive use and promotion, is available at: https://dongdongshen.shinyapps.io/DynNomapp/ .
Conclusion
This nomogram may serve as an effective tool for assessing frailty risk in older patients with ischaemic stroke.
Relevance to Clinical Practice
The nomogram in this study may assist healthcare professionals in identifying high‐risk patients with frailty and understanding related factors, thereby providing more personalised risk management.
Reporting Method
TRIPOD checklist.
Patient or Public Contribution
No patient or public contribution.
Huan Xi and colleagues argue that tailored strategies are needed to seamlessly integrate frailty assessment into multimorbidity management, thereby promoting a shift towards a health oriented management approach
The Tilburg Frailty Indicator (TFI) is a questionnaire for assessing frailty. It was developed on the basis of an integral conceptual model of frailty. The TFI contains 15 components of frailty referring to physical frailty (eight), psychological frailty (four), and social frailty (three). After publication of the TFI in 2010, many studies examined its psychometric properties. In many cases the reliability was satisfactory. With regard to criterion validity the findings were different, from excellent for disability to poor for some indicators of healthcare utilization (hospitalization). The TFI demonstrated good associations with lower quality of life. In addition, the construct validity of the TFI can be qualified as good. The results of the screening with the TFI can provide a first direction to the interventions that should be carried out next by healthcare professionals. The strength of the TFI is the multidimensional approach to frailty. It is characterized by a holistic view to take care of frail older people.
Aims
This study aimed to uncover hidden patterns and predictors of symptom multi-trajectories within 30 days after discharge in patients with heart failure and assess the risk of unplanned 30-day hospital readmission in different patterns.
Methods and results
The study was conducted from September 2022 to September 2023 in four third-class hospitals in Tianjin, China. A total of 301 patients with heart failure were enrolled in the cohort, and 248 patients completed a 30-day follow-up after discharge. Three multi-trajectory groups were identified: mild symptom status (24.19%), moderate symptom status (57.26%), and severe symptom status (18.55%). With the mild symptom status group as a reference, physical frailty, psychological frailty, and comorbid renal dysfunction were predictors of the moderate symptom status group. Physical frailty, psychological frailty, resilience, taking diuretics, and comorbid renal dysfunction were predictors of the severe symptom status group. Compared with the mild symptom status group, the severe symptom status group was significantly associated with high unplanned 30-day hospital readmission risks.
Conclusions
This study identified three distinct multi-trajectory groups among patients with heart failure within 30 days after discharge. The severe symptom status group was associated with a significantly increased risk of unplanned 30-day hospital readmission. Common and different factors predicted different symptom multi-trajectories. Healthcare providers should assess the physical and psychological frailty and renal dysfunction of patients with heart failure before discharge. Inpatient care aimed at alleviating physical and psychological frailty and enhancing resilience may be important to improve patients’ symptom development post-discharge.
Background and Objectives
This study aimed to investigate the diagnostic accuracy of four questionnaire-based tools (i.e., the FRAIL scale, Groningen Frailty Indicator [GFI], Tilburg Frailty Indicator [TFI], and PRISMA-7) for screening frailty in older adults.
Research Design and Methods
Four databases comprising the Cumulative Index to Nursing and Allied Health Literature, Embase, PubMed, and ProQuest were searched from inception to June 20, 2023. Study quality comprising risks of bias and applicability were assessed via a QUADAS-2 questionnaire. A bivariate network meta-analysis model and Youden's index were performed to identify the optimal tool and cutoff points.
Results
In total, 20 studies comprising 13 for FRAIL, seven for GFI, six for TFI, and five for PRISMA-7 were included. Regarding study quality appraisal, all studies had high risks of bias for study quality assessment domains. Values of the pooled sensitivity of the FRAIL scale, GFI, TFI, and PRISMA-7 were 0.58, 0.74, 0.66, and 0.73, respectively. Values of the pooled specificity of the FRAIL scale, GFI, TFI, and PRISMA-7 were 0.92, 0.77, 0.84, and 0.86, respectively. The Youden’s index indicated was obtained for the FRAIL scale with a cutoff of two points (Youden’s index = 0.65), indicating that the FRAIL scale with a cutoff of two points was the optimal tool for frailty screening in older adults.
Discussion and Implications
The FRAIL scale comprising five self-assessed items is a suitable tool to interview older adults for early frailty detection in community settings; it has advantages of being short, simple, and easy to respond to.
Introduction
With the progressive aging of the population, frailty is now a significant challenge in geriatrics research. A growing amount of evidence suggests that sleep disturbance and depression have independent effects on frailty, although the underlying mechanisms are not yet clear. This study aimed to investigate the mediating role of depression in the relationship between sleep disturbance and frailty in older adult patients with type 2 diabetes (T2DM) in the community.
Method
Purposive sampling was used to collect face-to-face data from 342 community-dwelling T2DM patients in Chengdu, Sichuan Province, China, between February and May 2023. The Pittsburgh Sleep Quality Index (PSQI) scale was used to evaluate sleep quality, the Simple Geriatric Depression Scale (GDS-15) was used to evaluate depressive symptoms, and the FRAIL Scale (FRAIL) was used to evaluate frailty. Linear regression equation and bootstrap self-sampling were used to verify the mediating role of depressive symptoms in sleep disturbance and frailty.
Result
The study found that sleep disturbance had a direct positive effect with frailty [β = 0.040, 95% CI: (0.013, 0.069)]. Additionally, depression had a direct positive effect on frailty [β = 0.130, 95% CI: (0.087, 0.173)], and depression was found to partially mediate the relationship between sleep disturbance and frailty.
Conclusion
Poor sleep quality and frailty are common in patients with T2DM. To reduce the frailty of older adult T2DM patients, all levels of society (government, medical institutions, and communities) must pay more attention to mental health. A variety of interventions should be considered to improve sleep quality and depression, which in turn may prevent or control frailty.
Background
Consistent and reproducible estimates of the underlying true level of frailty are essential for risk stratification and monitoring of health changes. The purpose of this study is to examine the reliability of the frailty index (FI).
Methods
A total of 426 community-dwelling older adults from the FRequent health Assessment In Later life (FRAIL70+) study in Austria were interviewed biweekly up to 7 times. Two versions of the FI, one with 49 deficits (baseline), and another with 44 (follow-up) were created. Internal consistency was assessed using confirmatory factor analysis and coefficient omega. Test–retest reliability was assessed with Pearson correlation coefficients and the intraclass correlation coefficient. Measurement error was assessed with the standard error of measurement, limits of agreement, and smallest detectable change.
Results
Participants (64.6% women) were on average 77.2 (±5.4) years old with mean FI49 at a baseline of 0.19 (±0.14). Internal consistency (coefficient omega) was 0.81. Correlations between biweekly FI44 assessments ranged between 0.86 and 0.94 and reliability (intraclass correlation coefficient) was 0.88. The standard error of measurement was 0.05, and the smallest detectable change and upper limits of agreement were 0.13; the latter is larger than previously reported minimal clinically meaningful changes.
Conclusions
Both internal consistency and reliability of the FI were good, that is, the FI differentiates well between community-dwelling older adults, which is an important requirement for risk stratification for both group-level oriented research and patient-level clinical purposes. Measurement error, however, was large, suggesting that individual health deteriorations or improvements, cannot be reliably detected for FI changes smaller than 0.13.FI).
Maintaining optimal health and a sense of attachment to one’s home and life space (i.e., neighbourhood) is the core of ageing in place. Life space can diminish over the life course due to a change in life goals as well as a gradual decline in functional ability. Climate change, infectious diseases, violence, and radical industrialisation, collectively referred to as the global crises, are being felt globally and may further limit access to life space, especially in later life. This chapter aims to provide a heuristic as a theoretical lens through which stakeholders can understand how the global crises affect life space and ageing in place. We utilised the heuristic to explain the concept of psychological distance and how it serves as a premise around which life space may diminish due to global crises. Implications for ageing in place are encapsulated in six postulates to guide future research and policy development. The chapter suggests a need for stakeholders to co-develop sustainable interventions to the global crises, enabling contexts or neighbourhoods to avoid alternating between episodes of these crises.
Introduction:
This study aimed to explore the associations of low hand grip strength (HGS), HGS asymmetry, their combinations, and frailty on hospital readmissions, total complications, and prolonged length of stay (PLOS) among older adults with gastric cancer.
Materials and methods:
This study included 342 patients with gastric cancer aged ≥60 years who were scheduled to undergo radical surgery. The Tilburg Frailty Indicator (TFI) was used to collect information on frailty. HGS was measured twice for each hand using an electronic handgrip dynamometer. The highest HGS readings on each hand were used for calculating the HGS asymmetry ratio: non-dominant HGS (kg)/dominant HGS (kg). The Fine and Gray proportional subdistribution hazard model and the logistic regression model were used for the analyses, with covariates adjusted.
Results:
Low HGS (subdistribution hazard ratios [SHR] = 2.10, 95% confidence interval [CI] = 1.05-3.93, P = 0.036) and low HGS with HGS asymmetry (SHR = 3.95, 95% CI = 1.50-10.36, P = 0.005) were significantly associated with hospital readmissions. Frailty was associated with total complications (odds ratio [OR] = 2.87, 95% CI = 1.61-5.13, P < 0.001) and PLOS (OR = 1.98, 95% CI = 1.19-3.29, P < 0.001). Low HGS, HGS asymmetry, and their combinations were not significantly associated with total complications and PLOS.
Discussion:
Preoperative low HGS and low HGS with HGS asymmetry were associated with hospital readmissions, while frailty was associated with total complications and PLOS among older adults with gastric cancer. In the future, more rigorously designed studies are needed to verify our results further to improve preoperative clinical assessment and frailty evaluation among older adults with gastric cancer.
Introduction:
Few studies have examined the life satisfaction of migrant older adults with children (MOAC), who emerged due to rapid urbanization and population aging in China. This study aimed to explore the chain mediating effect of mental health and sleep quality on the association between social support and life satisfaction among MOAC in Weifang, China.
Methods:
A cross-sectional study was conducted using multi-stage cluster random sampling, and 613 participants were included. The Social Support Rating Scale, Depression Anxiety Stress Scale, Pittsburgh Sleep Quality Index, and Scale with Life Satisfaction were used to measure the social support, mental health, sleep quality, and life satisfaction of MOAC, respectively. Descriptive statistics, t-tests, and ANOVA were used to explore the relationship between sociodemographic variables and life satisfaction. Pearson's correlation analysis and structural equation modeling (SEM) were conducted to investigate the association between social support, mental health, sleep quality, and life satisfaction.
Results:
The mean total SWLS score was 27.87±5.58. SEM analysis demonstrated that social support had a positive effect on life satisfaction (β= 0.197). Mental health and sleep quality partially mediated the association between social support and life satisfaction (95% CI: 0.083-0.193), and the mediating effect accounted for 39.198% of the total effect.
Conclusion:
Life satisfaction was relatively high, and mental health and sleep quality partially mediated the association between social support and life satisfaction. Policy suggestions were provided based on these results.
Background:
Frailty is widely recognised as a distinct multifactorial clinical syndrome that implies vulnerability. The links between frailty and adverse outcomes such as death and institutionalisation have been widely evidenced. There is currently no gold standard frailty assessment tool; optimizing the assessment of frailty in older people therefore remains a research priority. The objective of this systematic review is to identify existing multi-component frailty assessment tools that were specifically developed to assess frailty in adults aged ≥60 years old and to systematically and critically evaluate the reliability and validity of these tools.
Methods:
A systematic literature review was conducted using the standardised COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist to assess the methodological quality of included studies.
Results:
Five thousand sixty-three studies were identified in total: 73 of which were included for review. 38 multi-component frailty assessment tools were identified: Reliability and validity data were available for 21 % (8/38) of tools. Only 5 % (2/38) of the frailty assessment tools had evidence of reliability and validity that was within statistically significant parameters and of fair-excellent methodological quality (the Frailty Index-Comprehensive Geriatric Assessment [FI-CGA] and the Tilburg Frailty Indicator [TFI]).
Conclusions:
The TFI has the most robust evidence of reliability and validity and has been the most extensively examined in terms of psychometric properties. However, there is insufficient evidence at present to determine the best tool for use in research and clinical practice. Further in-depth evaluation of the psychometric properties of these tools is required before they can fulfil the criteria for a gold standard assessment tool.
Introduction:
Demographic changes in Japan have resulted in an increased number of elderly living alone.
Aim:
The aim of this study was to identify if there is an association between frailty and living alone.
Methods:
We conducted a cross-sectional study of 1602 Japanese men and women living in isolated islands. Information obtained included height, body weight, handgrip strength, and family structure; antihypertensive, hypoglycaemic, and lipid-lowering medication use; history of stroke or ischaemic heart disease, smoking history, alcohol intake, joint pain or swelling. Relevant laboratory test results were obtained from recent health check-ups. The Frailty Index for Japanese elderly, a 15-item self-report questionnaire was completed by participants and the Kessler Psychological Distress Scale (K6) was administered.
Results:
After individuals aged below 60 years old or those with missing data were excluded, data from 1224 participants were analysed. Living alone (single household family structure) was significantly associated with frailty in men (odds ratio [OR] 3.85; 95% confidence interval [CI] 1.94-7.65), but not in women (OR 1.08; 95% CI 0.72-1.63). This association in men remained statistically significant after adjustment for known risk factors for frailty.
Discussion:
In the elderly population in rural Nagasaki, men living alone have a high risk of frailty. Screening and intervention to prevent frailty in this population is urgently needed.
Aim
The aim of this study was to assess the psychometric properties of the Polish version of the Tilburg Frailty Indicator (TFI), an instrument that identifies frailty in the elderly population.
Material and methods
We interviewed 212 community dwelling elderly aged 60 or older (mean age:70.6 SD≥7.16). The validation (assessment of face validity, content validity was carried out in accordance with the literature. The Tilburg Frailty Indicator (TFI) consists of two different parts. One part addresses the potential determinants of frailty and the other specifically addresses the components of frailty, covering its physical, psychological and social domains. Scale reliability was estimated using two methods: Cronbach’s alpha, measuring the scale’s internal consistency, and the test-retest method, determining the scale’s absolute stability. To assess test-retest reliability, the same group was re-interviewed by the same observer within 10-14 days of the first interview
Results
The test-retest reliability showed a high level of agreement for all items of the instrument, with values ranging from 96 to 100%. The Cronbach’s Alpha internal consistency was 0.72.
Conclusion
The Polish version of the TFI proved to be a valid and reliable tool for assessment of FS for the Polish population.
Keywords frailty, questionnairies, validity, aging
The Tilburg frailty indicator (TFI) is a self-report measurement instrument which integrates the physical, psychological and social domains to assess frailty in older adults. The aim of this study was the adaptation of the TFI to a German version and testing of the psychometric properties.
This study surveyed 210 individuals aged 64-91 years living at home. The mean age of participants was M = 75.3±5.7 years with 62 % females. The internal consistency was tested with Cronbach's alpha. The test-retest reliability was calculated after 20 weeks. The German TFI was validated using alternative measures for assessment of the quality of life, e.g. Eurohis-QoL-8 and short form health survey (SF-12), the patient health questionnaire (PHQ), the geriatric anxiety inventory short form (GAI-SF), the social support scale (F-Soz-U-K-14) and the resilience scale (RS-11).
The internal consistency was acceptable with a value for Cronbach's alpha of 0.67. The test-retest reliability was good after 5 months α = 0.87 (physical domain r = 0.85, psychological domain r = 0.75 and social domain r = 0.84). The inter-item correlations ranged between - 0.06 and 0.57. Correlations with alternative frailty measures showed good convergent and divergent validity.
This study showed acceptable psychometric properties of the German adaptation of the TFI which was found to be age and frailty sensitive. The results of the validity of the TFI support the three domains integrated in the frailty score. Further application and testing of the German TFI in primary care and clinical settings are suggested to consolidate the findings.
Background:
frailty is a state of vulnerability to adverse outcomes. Routine identification of frailty is recommended in international guidance. This systematic review investigates the diagnostic test accuracy (DTA) of simple instruments for identifying frailty in community-dwelling older people.
Methods:
the review methodology followed Cochrane procedures. Databases were searched from January 1990 to October 2013. Prospective studies assessing the DTA of simple instruments for identifying frailty in community-dwelling older people (aged ≥65 years) as index tests against a reference standard phenotype model, cumulative deficit frailty index or comprehensive geriatric assessment were eligible for inclusion. Sensitivity, specificity, positive predictive value, negative predictive value and likelihood ratios were calculated for index tests. Risk of bias was assessed using the QUADAS-2 checklist.
Results:
three studies involving 3,261 participants were included. Median frailty prevalence was 10.5%. Seven index tests were assessed: gait speed, timed-up-and-go test, PRISMA 7 questionnaire, self-reported health, general practitioner clinical assessment, polypharmacy and Groningen Frailty Index. For a gait speed of <0.8 m/s, the sensitivity = 0.99 and specificity = 0.64. For the PRISMA 7, the sensitivity = 0.83 and specificity = 0.83. For the timed get-up-and-go test of 10 s, the sensitivity = 0.93 and specificity = 0.62. DTA was notably lower for all other index tests. All three studies were judged at unclear risk of bias.
Discussion:
slow gait speed, PRISMA 7 and the timed get-up-and-go test have high sensitivity for identifying frailty. However, limited specificity implies many false-positive results which means that these instruments cannot be used as accurate single tests to identify frailty.
Unlabelled:
Older people are majority users of health and social care services in the UK and internationally. Many older people who access these services have frailty, which is a state of vulnerability to adverse outcomes. The existing health care response to frailty is mainly secondary care-based and reactive to the acute health crises of falls, delirium and immobility. A more proactive, integrated, person-centred and community-based response to frailty is required. The British Geriatrics Society Fit for Frailty guideline is consensus best practice guidance for the management of frailty in community and outpatient settings.
Recognition of frailty:
The BGS recommends that all encounters between health and social care staff and older people in community and outpatient settings should include an assessment for frailty. A gait speed <0.8m/s; a timed-up-and-go test >10s; and a score of ≥3 on the PRISMA 7 questionnaire can indicate frailty. The common clinical presentations of frailty (falls, delirium, sudden immobility) can also be used to indicate the possible presence of frailty.
Management of frailty:
The BGS recommends an holistic medical review based on the principles of comprehensive geriatric assessment (CGA) for all older people identified with frailty. This will: diagnose medical illnesses to optimise treatment; apply evidence-based medication review checklists (e.g. STOPP/START criteria); include discussion with older people and carers to define the impact of illness; work with the older person to create an individualised care and support plan.
Screening for frailty:
The BGS does not recommend population screening for frailty using currently available instruments.
We created a 30-item Frailty Index in the Canadian Multicentre Osteoporosis Study. A Frailty Index is a sensitive measure that can quantify fracture risk according to degree of frailty. Our results indicated that at any age, frailty was an important independent risk factor for fracture over 10 years.
Introduction
In later life, frailty has been linked to fractures. It is likely that the antecedents of fracture are seen across the life course, in ways not entirely captured by traditional osteoporosis risk factors. Using data collected from the prospective, population-based Canadian Multicentre Osteoporosis Study (CaMos), we created the 30-item CaMos Frailty Index and examined whether it was associated with incident fractures over 10 years.
Methods
All CaMos participants aged 25 years and older (n = 9,423) were included in the analysis. To examine the relationship between baseline Frailty Index scores and incident fractures, a competing risk proportional sub-distribution hazards model was used with death considered a competing risk. Analyses were adjusted for age, sex, body mass index, education level, femoral neck T-score, and antiresorptive therapy.
Results
At baseline, the mean age was 62.1 years [standard deviation (SD) 13.4], and 69.4 % were women. The mean Frailty Index score was 0.13 (SD 0.11), ranging from 0 to 0.66. For every 0.10 increase in Frailty Index scores (approximately one SD), the hazard ratio was 1.25 (p < 0.001) for all fractures, 1.18 (p = 0.043) for hip fractures, and 1.30 (p ≤ 0.001) for clinical vertebral fractures.
Conclusion
The CaMos Frailty Index quantified fracture risk according to degree of frailty. Irrespective of age and bone mineral density, the Frailty Index was associated with hip, vertebral, and all-type clinical fractures. Predicting late onset illnesses may have to consider overall health status and not just traditional risk factors.
Although research productivity in the field of frailty has risen exponentially in recent years, there remains a lack of consensus regarding the measurement of this syndrome. This overview offers three services: first, we provide a comprehensive catalogue of current frailty measures; second, we evaluate their reliability and validity; third, we report on their popularity of use.
In order to identify relevant publications, we searched MEDLINE (from its inception in 1948 to May 2011); scrutinized the reference sections of the retrieved articles; and consulted our own files. An indicator of the frequency of use of each frailty instrument was based on the number of times it had been utilized by investigators other than the originators.
Of the initially retrieved 2,166 papers, 27 original articles described separate frailty scales. The number (range: 1 to 38) and type of items (range of domains: physical functioning, disability, disease, sensory impairment, cognition, nutrition, mood, and social support) included in the frailty instruments varied widely. Reliability and validity had been examined in only 26% (7/27) of the instruments. The predictive validity of these scales for mortality varied: for instance, hazard ratios/odds ratios (95% confidence interval) for mortality risk for frail relative to non-frail people ranged from 1.21 (0.78; 1.87) to 6.03 (3.00; 12.08) for the Phenotype of Frailty and 1.57 (1.41; 1.74) to 10.53 (7.06; 15.70) for the Frailty Index. Among the 150 papers which we found to have used at least one of the 27 frailty instruments, 69% (n = 104) reported on the Phenotype of Frailty, 12% (n = 18) on the Frailty Index, and 19% (n = 28) on one of the remaining 25 instruments.
Although there are numerous frailty scales currently in use, reliability and validity have rarely been examined. The most evaluated and frequently used measure is the Phenotype of Frailty.
"This paper advocates a validational process utilizing a matrix of intercorrelations among tests representing at least two traits, each measured by at least two methods. Measures of the same trait should correlate higher with each other than they do with measures of different traits involving separate methods. Ideally, these validity values should also be higher than the correlations among different traits measure by the same method." Examples from the literature are described as well as problems in the application of the technique. 36 refs. (PsycINFO Database Record (c) 2010 APA, all rights reserved)
The aim of this article is to discuss the concept of frailty and its adequacy in identifying and describing older adults as frail.
Despite the dramatic increase in use of the term 'frailty' over the past two decades, there is a lack of consensus in the literature about its meaning and use, and no clear conceptual guidelines for identifying and describing older adults as frail. Differences in theoretical perspectives will influence policy decisions regarding eligibility for, and allocation of, scarce health care resources among older adults.
The article presents a literature review and synthesis of definitions and conceptual models of frailty in relation to older adults. The first part of the paper is a summary of the synonyms, antonyms and definitions of the term frailty. The second part is a critical evaluation of conceptual models of frailty. Six conceptual models are analysed on the basis of four main categories of assumptions about: (1) the nature of scientific knowledge; (2) the level of analysis; (3) the ageing process; (4) the stability of frailty. The implications of these are discussed in relation to clinical practice, policy and research.
The review gives guidelines for a new theoretical approach to the concept of frailty in older adults: (1) it must be a multidimensional concept that considers the complex interplay of physical, psychological, social and environmental factors; (2) the concept must not be age-related, suggesting a negative and stereotypical view of ageing; (3) the concept must take into account an individual's context and incorporate subjective perceptions; (4) the concept must take into account the contribution of both individual and environmental factors.
The purpose of this study was to identify the incidence of frailty and to investigate the relationship between frailty status and health-related quality of life (HRQoL) in the community-dwelling elderly population who utilize preventive health services.
People aged 65 years and older who visited a medical center in Taipei City from March to August in 2011 for an annual routine check-up provided by the National Health Insurance were eligible. A total of 374 eligible elderly adults without cognitive impairment had a mean age of 74.6±6.3 years. Frailty status was determined according to the Fried frailty criteria. HRQoL was measured with Short Form-36 (SF-36). Multiple regression analyses examined the relationship between frailty status and the two summary scales of SF-36. Models were adjusted for the participants' sociodemographic and health status.
After adjusting for sociodemographic and health-related covariables, frailty was found to be more significantly associated (p<0.001) with lower scores on both physical and mental health-related quality of life summary scales compared with robustness. For the frailty phenotypes, slowness represented the major contributing factor in the physical component scale of SF-36, and exhaustion was the primary contributing factor in the mental component scale.
The status of frailty is closely associated with HRQoL in elderly Taiwanese preventive health service users. The impacts of frailty phenotypes on physical and mental aspects of HRQoL differ.
An operational definition of frailty is important for clinical care, research, and policy planning. The literature on the clinical definitions, screening tools, and severity measures of frailty were systematically reviewed as part of the Canadian Initiative on Frailty and Aging. Searches of MEDLINE from 1997 to 2009 were conducted, and reference lists of retrieved articles were pearled, to identify articles published in English and French on the identification of frailty in community-dwelling people aged 65 and older. Two independent reviewers extracted descriptive information on study populations, frailty criteria, and outcomes from the selected papers, and quality rankings were assigned. Of 4,334 articles retrieved from the searches and 70 articles retrieved from the pearling, 22 met study inclusion criteria. In the 22 articles, physical function, gait speed, and cognition were the most commonly used identifying components of frailty, and death, disability, and institutionalization were common outcomes. The prevalence of frailty ranged from 5% to 58%. Despite significant work over the past decade, a clear consensus definition of frailty does not emerge from the literature. The definition and outcomes that best suit the unique needs of the researchers, clinicians, or policy-makers conducting the screening determine the choice of a screening tool for frailty. Important areas for further research include whether disability should be considered a component or an outcome of frailty. In addition, the role of cognitive and mood elements in the frailty construct requires further clarification.
Exploring the domains and degrees of health-related quality of life (HRQOL) that are affected by the frailty of elders will help clinicians understand the impact of frailty. This association has not been investigated in community-dwelling elders. Therefore, we examined the domains and degree of HRQOL of elders with frailty in the community in Taiwan.
A total of 933 subjects aged 65 years and over were recruited in 2009 from a metropolitan city in Taiwan. Using an adoption of the Fried criteria, frailty was defined by five components: shrinking, weakness, poor endurance and energy, slowness, and low physical activity level. HRQOL was assessed by the short form 36 (SF-36). The multiple linear regression model was used to test the independent effects of frailty on HRQOL.
After multivariate adjustment, elders without frailty reported significantly better health than did the pre-frail and frail elders on all scales, and the pre-frail elders reported better health than did the frail elders for all scales except the scales of role limitation due to physical and emotional problems and the Mental Component Summary (MCS). The significantly negative differences between frail and robust elders ranged from 3.58 points for the MCS to 22.92 points for the physical functioning scale. The magnitude of the effects of frail components was largest for poor endurance and energy, and next was for slowness. The percentages of the variations of these 10 scales explained by all factors in the models ranged from 11.1% (scale of role limitation due to emotional problems) to 49.1% (scale of bodily pain).
Our study demonstrates that the disabilities in physical health inherent in frailty are linked to a reduction in HRQOL. Such an association between clinical measures and a generic measure of the HRQOL may offer clinicians new information to understand frailty and to conceptualize it within the broader context of disability.
Disability in Activities of Daily Living (ADL) is an adverse outcome of frailty that places a burden on frail elderly people, care providers and the care system. Knowing which physical frailty indicators predict ADL disability is useful in identifying elderly people who might benefit from an intervention that prevents disability or increases functioning in daily life. The objective of this study was to systematically review the literature on the predictive value of physical frailty indicators on ADL disability in community-dwelling elderly people.
A systematic search was performed in 3 databases (PubMed, CINAHL, EMBASE) from January 1975 until April 2010. Prospective, longitudinal studies that assessed the predictive value of individual physical frailty indicators on ADL disability in community-dwelling elderly people aged 65 years and older were eligible for inclusion. Articles were reviewed by two independent reviewers who also assessed the quality of the included studies.
After initial screening of 3081 titles, 360 abstracts were scrutinized, leaving 64 full text articles for final review. Eventually, 28 studies were included in the review. The methodological quality of these studies was rated by both reviewers on a scale from 0 to 27. All included studies were of high quality with a mean quality score of 22.5 (SD 1.6). Findings indicated that individual physical frailty indicators, such as weight loss, gait speed, grip strength, physical activity, balance, and lower extremity function are predictors of future ADL disability in community-dwelling elderly people.
This review shows that physical frailty indicators can predict ADL disability in community-dwelling elderly people. Slow gait speed and low physical activity/exercise seem to be the most powerful predictors followed by weight loss, lower extremity function, balance, muscle strength, and other indicators. These findings should be interpreted with caution because the data of the different studies could not be pooled due to large variations in operationalization of the indicators and ADL disability across the included studies. Nevertheless, our study suggests that monitoring physical frailty indicators in community-dwelling elderly people might be useful to identify elderly people who could benefit from disability prevention programs.
Frailty in individuals can be operationalized as the accumulation of health deficits, for which several trends have been observed in Western countries. Less is known about deficit accumulation in China, the country with the world's largest number of older adults.
This study analyzed data from the Beijing Longitudinal Study of Aging, to evaluate the relationship between age and deficit accumulation in men and women and to evaluate the impact of frailty on mortality. Community dwelling people aged 55+ years at baseline (n = 3275) were followed every two to three years between 1992 and 2000, during which time 36% died. A Frailty Index was constructed using 35 deficits, drawn from a range of health problems, including symptoms, disabilities, disease, and psychological difficulties.
Most deficits increased the eight-year risk of death and were more lethal in men than in women, although women had a higher mean level of frailty (Frailty Index = 0.11 ± 0.10 for men, 0.14 ± 0.12 for women). The Frailty Index increased exponentially with age, with a similar rate in men and women (0.038 vs. 0.039; r > 0.949, P < 0.01). A dose-response relationship was observed as frailty increased.
A Frailty Index employed in a Chinese sample, showed properties comparable with Western data, but deficit accumulation appeared to be more lethal than in the West.
To assess the reliability, construct validity, and predictive (concurrent) validity of the Tilburg Frailty Indicator (TFI), a self-report questionnaire for measuring frailty in older persons.
Cross-sectional.
Community-based.
Two representative samples of community-dwelling persons aged 75 years and older (n = 245; n = 234).
The TFI was validated using the LASA Physical Activity Questionnaire, BMI, Timed Up & Go test, Four test balance scale, Grip strength test, Shortened Fatigue Questionnaire, Mini-Mental State Examination, Center for Epidemiologic Studies Depression Scale, Anxiety subscale of the Hospital Anxiety and Depression Scale, Mastery Scale, Loneliness Scale, and the Social Support List. Adverse outcomes were measured using the Groningen Activity Restriction Scale and questions regarding health care use. Quality of life was measured using the WHOQOL-BREF.
The test-retest reliability of the TFI was good: 0.79 for frailty, and from 0.67 to 0.78 for its domains for a 1-year time interval. The 15 single components, and the frailty domains (physical, psychological, social) of the TFI correlated as expected with validated measures, demonstrating both convergent and divergent construct validity of the TFI. The predictive validity of the TFI and its physical domain was good for quality of life and the adverse outcomes disability and receiving personal care, nursing, and informal care.
This study demonstrates that the psychometric properties of the TFI are good, when performed in 2 samples of community-dwelling older people. The results regarding the TFI's validity provide strong evidence for an integral definition of frailty consisting of physical, psychological, and social domains.
To empirically evaluate the psychometric properties of the 15-item Geriatric Depression Scale (GDS-15); determine the optimal cutoff points and screening performance for the detection of major depression; and examine differential item functioning (DIF) to determine the variability of item responses across sociodemographics in an elderly home care population.
A secondary analysis of data collected from a random sample study.
Homebound subjects newly admitted over a 2-year-period to a large visiting nurse service agency in Westchester, New York.
Five hundred twenty-six subjects over age 65, newly admitted to home care for skilled nursing.
Major depression was diagnosed using both patient, Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, and best estimate procedures. Self-report measures included the GDS-15, activities of daily living (ADL), instrumental ADL, and pain intensity. Cognitive impairment was assessed using the Mini-Mental State Examination and medical morbidity using the Charlson Comorbidity Index.
Optimal cutoff (5) yielded sensitivity 71.8% and specificity of 78.2%, however, the accuracy of the GDS-15 was not influenced by severity of medical burden. Persons with a cluster of ailments were twice as likely (Adj odds ratio = 2.47; 95% confidence interval = 1.49-4.09) to be diagnosed with depression. DIF analyses revealed no variability of item responses across sociodemographics.
Main findings suggest that the accuracy of the GDS-15 was not influenced by severity of clinical or functional factors, or sociodemographics. This has broad implications suggesting that the very old, ill, and diverse populations can be appropriately screened for depression using the GDS-15.
Frailty can be measured in relation to the accumulation of deficits using a frailty index. A frailty index can be developed from most ageing databases. Our objective is to systematically describe a standard procedure for constructing a frailty index.
This is a secondary analysis of the Yale Precipitating Events Project cohort study, based in New Haven CT. Non-disabled people aged 70 years or older (n = 754) were enrolled and re-contacted every 18 months. The database includes variables on function, cognition, co-morbidity, health attitudes and practices and physical performance measures. Data came from the baseline cohort and those available at the first 18-month follow-up assessment.
Procedures for selecting health variables as candidate deficits were applied to yield 40 deficits. Recoding procedures were applied for categorical, ordinal and interval variables such that they could be mapped to the interval 0-1, where 0 = absence of a deficit, and 1= full expression of the deficit. These individual deficit scores were combined in an index, where 0= no deficit present, and 1= all 40 deficits present. The values of the index were well fit by a gamma distribution. Between the baseline and follow-up cohorts, the age-related slope of deficit accumulation increased from 0.020 (95% confidence interval, 0.014-0.026) to 0.026 (0.020-0.032). The 99% limit to deficit accumulation was 0.6 in the baseline cohort and 0.7 in the follow-up cohort. Multivariate Cox analysis showed the frailty index, age and sex to be significant predictors of mortality.
A systematic process for creating a frailty index, which relates deficit accumulation to the individual risk of death, showed reproducible properties in the Yale Precipitating Events Project cohort study. This method of quantifying frailty can aid our understanding of frailty-related health characteristics in older adults.
Little is known about the processes underlying the development of functional dependence. We set out to determine whether impairments in physical performance and cognitive status contribute independently to the risk of functional dependence in nondisabled older persons.
Among a probability sample of 1,103 community-living adults, aged 72 years and older, we evaluated the 945 subjects who reported no disability in the activities of daily living. Subjects underwent a comprehensive assessment, including physical performance and cognitive testing.
Among the 775 subjects alive with complete outcomes data, 221 (28.5%) developed dependence in activities of daily living at either the 1- or 3-year follow-up interview. The rates of functional dependence were 18%, 20%, 26%, and 50% (p < .001) and 18%, 23%, 31%, and 47% (p < .001), respectively, across quarters of worsening physical performance and cognitive status. Compared with subjects in the best group, those with the worst physical performance and cognitive status were more than five times as likely to develop functional dependence (67% vs 13%; p < .001). After adjustment for age, gender, number of chronic conditions, and housing stratum, the risk of functional dependence increased across quarters of both worsening physical performance (relative risks [RR] 1.0, 1.1, 1.3, 2.1) and cognitive status (RR 1.0, 1.3, 1.5, 2.0), independent of the effect of the other. Similar results were found for subjects who developed functional dependence at one year, for those who developed functional dependence at three years, and for the combined endpoint of functional dependence or death.
Impairments in physical performance and cognitive status contribute independently to the risk of functional dependence in nondisabled, community-living older adults. A better understanding of the processes underlying functional dependence may facilitate the design of effective and efficient strategies to prevent or slow functional decline.
There are increasing numbers of older African-Caribbeans in the UK. Primary care staff often feel less confident about diagnosing depression in this group. Screening instruments may assist in making diagnoses in cross-cultural consultations.
We aimed to determine the sensitivity and specificity of screening instruments for depression in older African-Caribbean people in Manchester, UK.
We carried out a two-stage study to compare three screening instruments for depression (Geriatric Depression Scale, Brief Assessment Schedule Depression Cards, Caribbean Culture Specific Screen), with a computerized diagnostic interview for mental health disorders in older adults (Geriatric Mental State). The study was set in inner-city Manchester. The subjects were community-resident African-Caribbeans aged 60 years and over; 227 subjects were approached. Of the 160 people screened, 130 agreed to diagnostic interview. The main outcome measures were Spearman correlation coefficients; these were calculated between each screening instrument and the diagnostic interview. Receiver-operating characteristic (ROC) curve analysis was used to determine appropriate sensitivity and specificity for each instrument.
The results for the largest subgroup, the Jamaicans (n = 96/130), demonstrated highly significant correlations between screening instruments and diagnostic interview (P < 0.001). Each instrument had a high sensitivity: Brief Assessment Schedule depression cards (cut-off > or =6; sensitivity 90.9% (95% CI 58.8-99.8), specificity 82.1% (95% CI 74.0-90.3)), Caribbean Culture Specific Screen (cut-off > or =6; sensitivity 90.9% (95% CI 58.8-99.8), specificity 74.1% (95% CI 64.8-83.4)), and Geriatric Depression Scale (cut-off > or =4; sensitivity 100% (95% CI 97.1-100), specificity 69.1% (95% CI 59.6-79.2)).
These screening instruments demonstrate high sensitivity levels, if an appropriate cut-off point is used. The culture-specific instrument did not perform better than the traditional instruments. Health professionals should approach the consultation in a culturally sensitive manner and use the validated instrument they are most familiar with.
This chapter examines the current state of research on frailty. A number of competing and complementary models for its development are described, followed by a working definition of frailty. Criteria for the identification of frailty in older individuals are discussed, and consideration is given to emotional, social, and psychological criteria, in addition to physical criteria of frailty. Promising future directions for research are noted throughout the chapter. The aim is to provide useful background information about frailty for researchers interested in the field. Frailty is an area of inquiry still early in its evolution.
Three terms are commonly used interchangeably to identify vulnerable older adults: comorbidity, or multiple chronic conditions,
frailty, and disability. However, in geriatric medicine, there is a growing consensus that these are distinct clinical entities
that are causally related. Each, individually, occurs frequently and has high import clinically. This article provides a narrative
review of current understanding of the definitions and distinguishing characteristics of each of these conditions, including
their clinical relevance and distinct prevention and therapeutic issues, and how they are related. Review of the current state
of published knowledge is supplemented by targeted analyses in selected areas where no current published data exists. Overall,
the goal of this article is to provide a basis for distinguishing between these three important clinical conditions in older
adults and showing how use of separate, distinct definitions of each can improve our understanding of the problems affecting
older patients and lead to development of improved strategies for diagnosis, care, research, and medical education in this
area.
Selecting elderly persons who need geriatric interventions and making accurate treatment decisions are recurring challenges in geriatrics. Chronological age, although often used, does not seem to be the best selection criterion. Instead, the concept of frailty, which indicates several concurrent losses in resources, can be used.
The predictive values of chronological age and frailty were investigated in a large community sample of persons aged 65 years and older, randomly drawn from the register of six municipalities in the northern regions of the Netherlands (45% of the original addressees). The participants' generative capacity to sustain well-being (i.e., self-management abilities) was used as the main outcome measure.
When using chronological age instead of frailty, both too many and too few persons were selected. Furthermore, frailty related more strongly (with beta values ranging from -.25 to -.39) to a decline in the participants' self-management abilities than did chronological age (with beta values ranging from -.06 to -.14). Chronological age added very little to the explained variances of all outcomes once frailty was included.
Using frailty as the criterion to select older persons at risk for interventions may be better than selecting persons based only on their chronological age.
There is no single generally accepted clinical definition of frailty. Previously developed tools to assess frailty that have been shown to be predictive of death or need for entry into an institutional facility have not gained acceptance among practising clinicians. We aimed to develop a tool that would be both predictive and easy to use.
We developed the 7-point Clinical Frailty Scale and applied it and other established tools that measure frailty to 2305 elderly patients who participated in the second stage of the Canadian Study of Health and Aging (CSHA). We followed this cohort prospectively; after 5 years, we determined the ability of the Clinical Frailty Scale to predict death or need for institutional care, and correlated the results with those obtained from other established tools.
The CSHA Clinical Frailty Scale was highly correlated (r = 0.80) with the Frailty Index. Each 1-category increment of our scale significantly increased the medium-term risks of death (21.2% within about 70 mo, 95% confidence interval [CI] 12.5%-30.6%) and entry into an institution (23.9%, 95% CI 8.8%-41.2%) in multivariable models that adjusted for age, sex and education. Analyses of receiver operating characteristic curves showed that our Clinical Frailty Scale performed better than measures of cognition, function or comorbidity in assessing risk for death (area under the curve 0.77 for 18-month and 0.70 for 70-month mortality).
Frailty is a valid and clinically important construct that is recognizable by physicians. Clinical judgments about frailty can yield useful predictive information.
This study aims to assess the reliability, construct validity (convergent/divergent), and criterion validity of the Italian version of the Tilburg Frailty Indicator (TFI). The TFI is a self-report questionnaire for screening frailty in older adults. Two hundred and sixty-seven community-dwelling older adults were involved. Psychometric properties were analyzed using validated instruments. Adverse outcomes such as disability, falls, and visits to a general practitioner were detected. Participants were mainly women (59.9%), with a mean age of 73.4 years (SD = 6.0). Internal consistency reliability was acceptable. Construct validity was good, since each item of the TFI correlated as expected with corresponding frailty measures. Convergent and divergent validity were adequate for all the domains of the TFI. Criterion validity was excellent for disability and mediocre for the other two outcomes. This study supports the validity of the Italian TFI and offers to clinicians and scientists a multidimensional instrument for identifying frail individuals in the Italian context.
Although multiple longitudinal studies have investigated frailty as a predictor of future falls, the results were mixed. Thus far, no systematic review or meta-analysis on this topic has been conducted.
To review the evidence of frailty as a predictor of future falls among community-dwelling older people.
Systematic review of literature and meta-analysis were performed using 6 electronic databases (Embase, Scopus, MEDLINE, CINAHL Plus, PsycINFO, and the Cochrane Library) searching for studies that prospectively examined risk of future fall risk according to frailty among community-dwelling older people published from 2010 to April 2015 with no language restrictions.
Of 2245 studies identified through the systematic review, 11 studies incorporating 68,723 individuals were included in the meta-analysis. Among 7 studies reporting odds ratios (ORs), frailty and prefrailty were significantly associated with higher risk of future falls (pooled OR = 1.84, 95% confidence interval [95% CI] = 1.43-2.38, P < .001; pooled OR = 1.25, 95% CI = 1.01-1.53, P = .005, respectively). Among 4 studies reporting hazard ratios (HRs), whereas frailty was significantly associated with higher risk of future falls (pooled HR = 1.24, 95% CI = 1.10-1.41, P < .001), future fall risk according to prefrailty did not reach statistical significance (pooled HR = 1.14, 95% CI = 0.95-1·36, P = .15). High heterogeneity was noted among 7 studies reporting ORs and seemed attributed to difference in gender proportion of cohorts according to subgroup and meta-regression analyses.
Frailty is demonstrated to be a significant predictor of future falls among community-dwelling older people despite various criteria used to define frailty. The future fall risk according to frailty seemed to be higher in men than in women.
Copyright © 2015 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.
The two most commonly employed frailty measures are the frailty phenotype and the frailty index. We compared them to examine whether they demonstrated common characteristics of frailty scales, and to examine their association with adverse health measures including disability, self-reported health, and healthcare utilization. The study examined adults aged 50+ (n=4096) from a sequential, cross-sectional sample (2003-2004; 2005-2006), National Health and Nutrition Examination Survey. The frailty phenotype was modified from a previously adapted version and a 46-item frailty index was created following a standard protocol. Both measures demonstrated a right-skewed distribution, higher levels of frailty in women, exponential increase with age and associations with high healthcare utilization and poor self-reported health. More people classified as frail by the modified phenotype had ADL disability (97.8%) compared with the frailty index (56.6%) and similarly for IADL disability (95% vs. 85.6%). The prevalence of frailty was 3.6% using the modified frailty phenotype and 34% using the frailty index. Frailty index scores in those who were classified as robust by the modified phenotype were still significantly associated with poor self-reported health and high healthcare utilization. The frailty index and the modified frailty phenotype each confirmed previously established characteristics of frailty scales. The agreement between frailty and disability was high with each measure, suggesting that frailty is not simply a pre-disability stage. Overall, the frailty index classified more people as frail, and suggested that it may have the ability to discriminate better at the lower to middle end of the frailty continuum.
Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.
Aim: To present the translation and validation process of the Portuguese version of the Tilburg Frailty Indicator (TFI).
Methods: A cross-sectional study was designed using a non-probability sample of 252 community-dwelling older adults. Preliminary studies were carried out for face and content validity assessment. Internal consistency, test–retest reliability, construct (convergent/divergent) and criterion validity were subsequently analyzed.
Results: The sample was mainly women (75.8%), with a mean age of 79.2 ± 7.3 years. TFI internal consistency was good (KR-20 = 0.78). Test–retest reliability for the total was also good (r = 0.91), with kappa coefficients showing substantial agreement for most items. TFI physical and social domains correlated as expected with concurrent measures, whereas the TFI psychological domain showed similar correlations with other psychological and physical measures. The TFI showed a good to excellent discrimination ability in regard to frailty criteria, and fair to good ability to predict adverse outcomes.
Conclusions: The psychometric properties of the TFI seem to be consistently good. These findings provide initial evidence that the Portuguese version is a valid and reliable measure for assessing frailty in the elderly.
Geriatr Gerontol Int 2014; ●●: ●●–●●.
The Tilburg Frailty Indicator (TFI) is a self-administered questionnaire with a bio-psycho-social integrated approach that measures the degree of frailty in elderly persons. The TFI was developed in the Netherlands and tested in a population of elderly Dutch men and women. The aim of this study was to translate and culturally adapt the TFI to a Danish context, and to test face validity of the Danish version by cognitive interviewing. An internationally recognized procedure was applied as a basis for the translation process. The primary tasks were forward translation, reconciliation, back translation, harmonization and pretest. Pretest and review of the preliminary version by cognitive interviewing, were performed at a local community centre and in an acute medical ward at the University Hospital in Aalborg, Denmark respectively. A large agreement regarding meaning of the items in the forward translation and reconciliation process was seen. Minor discrepancies were solved by consensus. Back translation revealed unclear wording in one matter. The harmonization committee agreed on a version for cognitive interviewing after revision of minor issues and thirty-four participants were interviewed. Two issues became evident and these were revised. The cognitive interviews and final lay-out resulted in minor adjustments as text type size, specific font, and lining for optimizing readability. In conclusion, we consider the TFI to be translated in such rigorous manner that the instrument can be further tested in clinical practice. The overall objective of the questionnaire being to identify frailty and improve the interventions relating to frail elderly persons in Denmark.
This study aims to assess the psychometric properties of the Brazilian version of the TFI, an instrument that identifies frailty in elderly individuals. We interviewed 219 individuals aged 60 or older, living in the community. Individuals were predominantly female (52.5%) and mean age was 70.5 (±7.9) years. In order to assess test-retest reliability, 101 individuals were re-interviewed by the same observer within seven to ten days after the first interview. The internal consistency of the instrument was assessed using Cronbach's alpha. To assess construct validity, we used established alternative measures for the items that constitute the TFI, such as: body mass index (BMI), timed up and go (TUG) test, whisper test, Snellen test, upper extremity strength clinical test and mini-mental state examination (MMSE). The test-retest reliability showed high percent agreement for all the items of the instrument, with values ranging from 63% to 100%. Test-retest reliabilities were good (total TFI score r=0.88; physical domain r=0.88; psychological domain r=0.88; and social domain r=0.67). Internal consistency reliability of the Brazilian version was satisfactory (Cronbach's alpha=0.78). The correlations between TFI items and their corresponding measures were consistent except for one item (related to "ability to deal with problems"), demonstrating both convergent and divergent construct validity of the TFI and its items. After the completion of all stages of transcultural adaptation, the Brazilian version of the TFI proved to be well suited for assessing frailty in the elderly population of Brazil.
Two aspects of translation were investigated: (1) factors that affect translation quality, and (2) how equivalence between source and target versions can be evaluated. The variables of language, content, and difficulty were studied through an analysis of variance design. Ninety-four bilinguals from the University of Guam, representing ten languages, translated or back-translated six essays incorporating three content areas and two levels of difficulty. The five criteria for equivalence were based on comparisons of meaning or predictions of similar responses to original or translated versions. The factors of content, difficulty, language and content-language interaction were significant, and the five equivalence criteria proved workable. Conclusions are that translation quality can be predicted, and that a functionally equivalent translation can be demonstrated when responses to the original and target versions are studied.
Established the validity and reliability of the General Health Questionnaire-30 items version, Short Portable Mental Status Questionnaire (SPMSQ), Center for Epidemiologic Studies Depression Scale, and Life Satisfaction Index-Form A to assess the mental health and mental status of elderly people in Hong Kong. 91 normal elderly or psychiatric patients with depression, senile dementia, Alzheimer's disease, and paranoid disorder (aged 60+ yrs) participated. The study adopted a 2-group comparison method conducted in 3 stages: evaluation of internal consistency, assessment of discriminative power, and assessment of test–retest reliability. Results indicate that the instruments had satisfactory reliability and very good discriminatory validity. An adjustment of the SPMSQ is proposed to take into consideration the effect of the educational background of the people of Hong Kong. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Frailty is the loss of resources in several domains leading to the inability to respond to physical or psychological stress. The evaluation of frailty is generally carried out using the Comprehensive Geriatric Assessment. For this evolving and potentially reversible syndrome, screening and early intervention are a priority in primary health care, and general practitioners require a simple screening tool. The aim of the present work was to review the literature for validated screening instruments for frailty in primary health care setting. A search was carried out on PubMed and Cochrane Central in June 2011. A total of 10 instruments screening for frailty in primary health care were listed, analysed and compared. It is difficult to show which tool today is the best for screening for frailty in the elderly in primary care settings. Two instruments are potentially suitable - the Tilburg Frailty Indicator and the SHARE Frailty Index. In addition, these instruments require validation in larger studies in primary health care settings and with more quality criteria.
Frailty is a known risk factor for those aged 65 and over, and its prevalence increases with age. Definitions of frailty vary widely, and prevalence estimates are affected by the way frailty is defined. Systematic reviews have yet to examine the literature on the association between definitions of frailty and mortality. We examined the definitions and prevalence of frailty and its association with survival in older community-dwelling adults. We conducted a systematic review of observational population-based studies published in English. We calculated pooled prevalence of frailty with a random effects model. We identified 24 population-based studies that examined frailty in community-dwelling older adults. The pooled prevalence was 14% when frailty was defined as a phenotype exhibiting three or more of the following: weight loss, fatigue/exhaustion, weakness, low physical activity/slowness, and mobility impairment. The pooled prevalence was 24% when frailty was defined by accumulation of deficits indices that included up to 75 diseases and impairments. The prevalence of frailty increased with age and was greater in women and in African Americans. Frailty in older adults was associated with poor survival with a dose-responsive reduction in survival per increasing number of frailty criteria. Taking into account population prevalence and multivariate adjusted relative risks, we estimated that 3-5% of deaths among older adults could be delayed if frailty was prevented. Frailty is a prevalent and important geriatric syndrome associated with decreased survival. Geriatric assessment of frailty provides clinically important information about functional status and survival of older adults.
To determine which determinants predict frailty and domains of frailty (physical, psychological, social) in a community-dwelling sample of elderly persons.
Cross-sectional.
Community-based.
A representative sample of 484 community-dwelling persons aged 75 years and older.
The Tilburg Frailty Indicator (TFI), a self-report questionnaire, was used to collect information about determinants of frailty and to assess frailty and domains of frailty (physical, psychological, social).
Results were obtained by regression and mediation analyses. The 10 determinants explain about 35% of the variance of frailty. After controlling for other determinants, medium income, an unhealthy lifestyle, and multimorbidity predicted frailty. The effects of other determinants differed across domains of frailty; age predicted physical frailty, life events predicted psychological frailty, whereas being a woman predicted social frailty because older women have a higher probability of living alone.
Our finding that the effect of the determinants of frailty differs across frailty domains suggests that it is essential to divide the concept of frailty into domains.
This study estimated the prevalence of frailty and identified the factors associated with frailty in Taiwan using data from the Survey of Health and Living Status of the Elderly. A nationwide probability sample including 2,238 individuals aged > or =65 years was interviewed in 2003. Based on the Cardiovascular Health Study conducted by Fried, five phenotypes of frailty were selected: poor appetite, exhaustion, low physical activity, poor walking ability, and poor twisting ability of fingers. Participants were classified as nonfrail, prefrail, and frail if they met 0, 1 or 2, and > or =3 criteria. The prevalences of nonfrailty, prefrailty, and frailty were 55.1%, 40.0%, and 4.9%, respectively. The prevalence of frailty increased with age and was greater in women. Frailty was associated with less education, no spouse, disability, higher rates of comorbid chronic diseases, depressive symptoms, and geriatric syndromes. Specific drug use, such as hypnotics, analgesics, herbal drugs, and parenteral fluid supplements was positively associated with frailty. The use of multivitamins, fish oil, and vitamin E was negatively associated with frailty. The prevalence of frailty is lower in Taiwan than in Western countries. Depressive symptoms, geriatric syndromes, and specific medication use are potential fields for frailty prevention in community-dwelling older adults.
There has been relatively little research into health inequalities in older populations. This may be partly explained by the difficulty in identifying appropriate indicators of socio-economic status for older people. Ideally, indicators of socio-economic status to be used in studies of health inequalities in older populations should incorporate some measure of life-time socio-economic standing, and house value may fill this role. This study examined whether an indicator of accumulated wealth based on a combination of housing tenure and house value was a strong predictor of ill-health in older populations.
A total of 191 848 people aged > or =65 years and not living in communal establishments were identified from the 2001 Northern Ireland Census and followed for 5 years. Self-reported health and mortality risk by housing tenure/house value groupings were examined while controlling for a range of other demographic and socio-economic characteristics.
Housing tenure/house value was highly correlated with other indicators of socio-economic status. Public-sector renters had worse self-reported health and higher mortality rates than owner occupiers but significant gradients were also found between those living in the highest- and lowest-valued owner-occupier properties. The relationship between housing tenure and value was unchanged by adjustment for indicators of social support and quality of the physical environment. Adjustment for limiting long-term illness and self-reported health at baseline narrowed but did not eliminate the health gains associated with living in more expensive housing.
House value of residence is an accessible and powerful indicator of accumulated wealth that is highly correlated with current health status and predictive of future mortality risk in older populations.
To determine whether adding cognitive impairment to frailty improves its predictive validity for adverse health outcomes.
Four-year longitudinal study.
The French Three-City Study.
Six thousand thirty community-dwelling persons aged 65 to 95.
Frailty was defined as having at least three of the following criteria: weight loss, weakness, exhaustion, slowness, and low physical activity. Subjects meeting one or two criteria were prefrail and those meeting none as nonfrail. The lowest quartile in the Mini-Mental State Examination (MMSE) and the Isaacs Set Test (IST) was used to identify subjects with cognitive impairment. The predictive validity of frailty for incident disability, hospitalization, dementia, and death was calculated first for frailty subgroups and then rerun after stratification according to the presence or absence of cognitive impairment.
Four hundred twenty-one individuals (7%) met frailty criteria. Cognitive impairment was present in 10%, 12%, and 22% of the nonfrail, prefrail, and frail subjects, respectively. Those classified as frail scored lower on the MMSE and IST than those classified as prefrail and nonfrail. After adjustment, frail persons with cognitive impairment were significantly more likely to develop disability in activities of daily living (ADLs) and instrumental ADLs over the following 4 years. The risk of incident mobility disability and hospitalization was marginally greater. Incident dementia was greater in the groups with cognitive impairment irrespective of their frailty status. Conversely, frailty was not a significant predictor of mortality.
Cognitive impairment improves the predictive validity of the operational definition of frailty, because it increases the risk of adverse health outcomes in this particular subgroup of the elderly population.
This paper presents a general statistical methodology for the analysis of multivariate categorical data arising from observer reliability studies. The procedure essentially involves the construction of functions of the observed proportions which are directed at the extent to which the observers agree among themselves and the construction of test statistics for hypotheses involving these functions. Tests for interobserver bias are presented in terms of first-order marginal homogeneity and measures of interobserver agreement are developed as generalized kappa-type statistics. These procedures are illustrated with a clinical diagnosis example from the epidemiological literature.
Clinicians whose practice includes elderly patients need a short, reliable instrument to detect the presence of intellectual impairment and to determine the degree. A 10-item Short Portable Mental Status Questionnaire (SPMSQ), easily administered by any clinician in the office or in a hospital, has been designed, tested, standardized and validated. The standardization and validation procedure included administering the test to 997 elderly persons residing in the community, to 141 elderly persons referred for psychiatric and other health and social problems to a multipurpose clinic, and to 102 elderly persons living in institutions such as nursing homes, homes for the aged, or state mental hospitals. It was found that educational level and race had to be taken into account in scoring individual performance. On the basis of the large community population, standards of performance were established for: 1) intact mental functioning, 2) borderline or mild organic impairment, 3) definite but moderate organic impairment, and 4) severe organic impairment. In the 141 clinic patients, the SPMSQ scores were correlated with the clinical diagnoses. There was a high level of agreement between the clinical diagnosis of organic brain syndrome and the SPMSQ scores that indicated moderate or severe organic impairment.
To study the reliability and validity of Chinese version of International Physical Activity Questionnaire (IPAQ) and to provide an instrument for physical activity measurement in Chinese-spoken population.
Test-retest reliability was systemically assessed in 94 participants sampled from college students. Questionnaires were completed twice with a three-day interval. The validity was established in 39 volunteers by Caltrac accelerometer monitoring and 24-hour activity recording for seven consecutive days.
Both long vision (LV) and short vision (SV) had intraclass correlation coefficients above 0.7 for physical activity. The total energy expenditure measured by LV, SV and PA records were 264.5 +/- 260.9, 185.4 +/- 128.9 (compared with activity records, P < 0.05) and 250.5 +/- 141.2 MET-min/d respectively. Energy expenditure of moderate physical activity were 81.7 +/- 165.4, 32.0 +/- 42.5 (compared with activity record, P < 0.05) and 61.3 +/- 72.0 MET-min/d. Caltrac accelerometer was moderately correlated with LV (r = 0.50) and SV (r = 0.63) while SV measured total daily energy expenditure was lower than activity records. When participants were categorized into two groups according to their time spent in physical activity above or below the target level, proportions of agreement of questionnaires and 24-hour activity records were high, including vigorous physical activity above 90% and moderate physical activity above 70%. LV, SV and activity records were measured during sedentary condition at an approximate level.
Both LV and SV of IPAQ appeared to have acceptable reliability and validity, compared to other physical activity instruments that were used in various large epidemiological studies. The total or physical energy expenditures were similar between LV and activity records. For activity levels, the proportion of agreement were similar between activity records and LV or SV. However, SV underestimated the energy expenditure of total and moderate physical activity.
To measure relative fitness and frailty in older people without specific frailty instruments and to relate that measurement to long-term health outcomes.
Retrospective cohort studies.
Two population-based studies of people aged approximately 70 at baseline and followed up to 10 years (in the Canadian Study of Health and Aging (CSHA)) or 26 years in the Gothenburg H-70 cohort study.
Nine hundred sixty-two men and 1,178 women.
Deficit accumulation (the exposure) was counted using self-reported (CSHA) or clinically designated (H-70) symptoms, signs, diseases, and disabilities. Relative fitness and frailty were measured in relation to the degree of deficit accumulation evaluated in four quartiles, representing those most fit to those most frail. The items that made up the frailty index were selected randomly without replacement in 1,000 iterations. The outcomes were risks of death or residential long-term care.
Worse frailty, however measured, was associated with worse survival; the Kaplan-Meier curves of random iterations of the frailty definition showed virtually no interquartile overlap for mortality. For any given level of frailty, men died younger than women. Worse frailty was also associated with a higher risk of institutionalization.
Frailty appears to be a robust concept that is readily operationalized, with the risk of adverse outcomes being largely established by age 70.