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Cross-cultural adaptation and psychometric properties of the Groningen Frailty Indicator (GFI) among Chinese community-dwelling older adults
Abstract
The objective was to examine the feasibility, reliability and validity of the Groningen Frailty Indicator (GFI) among Chinese community-dwelling older adults. Of the 1230 participants, 1202 (97.7%) completed all items on the GFI. The internal consistency was acceptable (Cronbach's α = 0.64), and the test-retest reliability within a 7-15-day interval was good (ICC = 0.87). The GFI showed good diagnostic accuracy in the identification of frailty with reference to the frailty index (AUC = 0.84), and the optimal frailty cut-point was 3. Convergent validity was supported by significant correlations between each domain of the GFI and the corresponding alternative measurement(s). Higher proportions of frailty (GFI ≥ 3) were found in those who were older, female, less-educated, lived alone, and had 2 or more chronic diseases than in their counterparts, supporting its known-group discriminant validity. The Chinese GFI has good feasibility, acceptable reliability and satisfactory validity among community-dwelling older adults.
... The GFI has good diagnostic properties for screening frailty, with an optimal frailty cutoff of 3 points. 74 It is important to note that the GFI utilizes a self-assessment method, involving fewer items than the FI. The Chinese version of the GFI is semantically equivalent to the original text, with good reliability and validity. ...
... Furthermore, the Chinese versions of the TFI and GFI exhibit lower frailty thresholds when applied to the Chinese community compared to older adults in other countries. 74,77 This may be due to the fact that Chinese older people have different perceptions of the extent to which their health problems affect their lives than those of other countries. The Sinicized frailty scale's optimal cut-off values should be adjusted to suit the perceptions of Chinese. ...
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.
... Goodness of fit was determined using the goodness-of-fit index (GoF). The GoF measures how well the model fits the data by assessing the model's implicit covariance matrix, with a value above 0.5 indicating a good fit of the model to the data (Tian et al., 2020). The convergent validity of the model was assessed using the average variance extracted (AVE), with values above 0.5 considered acceptable, indicating that the latent variable is measured by at least 50% of the items (Dabbous & Barakat, 2020). ...
RESUMEN Entrepreneurship has emerged as a crucial factor in economic development, especially in developing nations, where the COVID-19 pandemic has exacerbated socioeconomic challenges , particularly in rural areas. Despite these adversities, countries like Colombia boast abundant natural resources and a dynamic young population, creating a conducive environment for sustainable economic growth. In this context, the main objective of this study was to conduct a comprehensive analysis of the factors influencing entrepreneurial intention in academic settings related to agriculture. To achieve this, a structural equation modeling was conducted on a sample of 200 agronomic engineering students at the Universidad Nacional de Colombia. This analysis identified the positive impact of entrepreneurial self-efficacy and opportunity recognition on entrepreneurial intention. The research focused on understanding entrepreneurial spirit among young individuals, acknowledging its significance as a driver of economic and social development. El emprendimiento se posiciona como un factor crucial para el desarrollo económico, especialmente en naciones en desa-rrollo, donde la pandemia de COVID-19 ha agravado los retos socioeconómicos, sobre todo en áreas rurales. A pesar de estas adversidades, países como Colombia cuentan con vastos recursos naturales y una población juvenil dinámica, creando un escenario propicio para un crecimiento económico soste-nible. En este contexto, el objetivo principal de este estudio es realizar un análisis exhaustivo de los factores que inciden en la intención emprendedora en entornos estudiantiles relacio-nados con la agricultura. Para lograr este objetivo, se llevó a cabo un modelo de ecuaciones estructurales en una muestra de 200 estudiantes de ingeniería agronómica en la Universidad Nacional de Colombia. Este análisis permitió reconocer el impacto positivo de la autoeficacia emprendedora y el recono-cimiento de oportunidades en la intención emprendedora. La investigación se centró en comprender el espíritu emprendedor de los jóvenes, reconociendo su importancia como motor del desarrollo económico y social.
... This finding aligns with the results of Hanlon et al. [42], where the prevalence of frailty increases as the number of chronic conditions rises in older adults. This may be attributed to degenerative physiological changes and the influence of various complex diseases in older adults [8][9][10][43][44][45][46]. Elevated blood levels of pro-inflammatory markers, such as IL-6, significantly contribute to inflammation, which is a primary risk factor with comorbid. ...
Background
As the global aging process accelerates, the older population is increasing annually, with the majority suffering from one or more chronic diseases. Due to the influence of chronic disease comorbidity, frailty among the older is widespread. Therefore, early identification of frailty in older adults with comorbidities from a comprehensive perspective, along with proactive measures for prevention and timely intervention, becomes an inevitable requirement for healthy aging. This study aimed to identify the entry point of frailty management in the older with multimorbidity in the community and clarify the focus of frailty management.
Methods
A national cross-sectional survey of 1056 older adults with comorbidities in 148 cities across China was conducted. Frailty was assessed using the Fatigue, Resistance, Ambulation, Illnesses, and Loss of weight (FRAIL) scale. Based on the health ecological model, the factors which may influence frailty were collected from five levels. Univariate and multivariate analysis were utilized to determine the factors influencing frailty. The STROBE checklist was used preparing the manuscript.
Results
A total of 417 patients (39.5%) reported having frailty, while 613 patients (58.0%) were in the pre-frail state. Multivariate logistic regression analysis indicate that compared with robust patients, number of comorbidities, self-efficacy, sleep quality and perceived social support are associated with frailty in older patients with comorbidities (P < 0.05). Compared to pre-frail group, factors such as number of comorbidities, gender (female), cognitive status of diseases, anxiety, having four or more comorbidities, smoking, eating habits, taking three or more different types of medication and perceived social support are associated with frailty (P < 0.05).
Conclusions
The prevalence of frailty among older adults with comorbidities is exceptionally high, influenced by various dimensions from health ecology perspective. Psychological care and daily behavior management should be strengthened for the frail older with multimorbidity. Precise and individualized care interventions need to be developed to help promote healthy aging.
... These findings indicate exceptional reliability, validity and internal consistency, thereby endorsing its use in clinical assessments. 27 Sample size calculation In this study, we will use MACEs as the primary outcome measure. The sample size will be determined using the single ROC curve calculation method via PASS11.0, ...
Introduction
Frailty significantly influences the prognosis of elderly patients diagnosed with heart failure. The assessment of frailty is a critical initial step in the management of these patients, as a systematic and precise evaluation facilitates the identification of individuals at high risk. This identification enables timely and targeted interventions, which can subsequently reduce the likelihood of adverse cardiovascular events and improve the quality of life for elderly patients with heart failure. Nevertheless, there exists a notable deficiency in research regarding the most effective frailty assessment tools specifically for elderly patients with heart failure in China. The objective of this study is to identify the frailty assessment tool that demonstrates the highest predictive value for outcomes in this population.
Methods and analysis
This study is a multicentre, prospective cohort investigation that commenced in October 2023 across three tertiary hospitals in Beijing, China. Employing a continuous enrolment strategy, the study encompasses all elderly patients diagnosed with heart failure who are undergoing either outpatient or inpatient treatment, continuing until an adequate sample size is achieved. Follow-up evaluations are scheduled every 3 months from the point of patient enrolment, extending until the 12th month post-enrolment. Comprehensive data collection, which includes demographic information, heart failure-related metrics, frailty assessments and significant biochemical test results, is conducted through face-to-face interviews at baseline.
Ethics and dissemination
Participant inclusion will depend on obtaining written informed consent from the patient or guardian. The trial protocol was approved by the Central Ethics Committee of Beijing Hospital. The approval letter number is 2023BJYYEC-356-01. Outcomes of the study will be published in a peer-reviewed scientific journal.
... The successful psychometric evaluation of the Arabic-translated GHBQ has significant implications for geriatric healthcare and research in Arabic-speaking communities. By providing a reliable and culturally tailored tool, this study contributes to the advancement of comprehensive health behavior assessments among the older adults population, enabling healthcare providers and researchers to gain valuable insights and develop targeted interventions [38,39]. ...
Background
The Geriatrics Health Behavior Questionnaire (GHBQ) is essential for assessing health-related behaviors among older adults populations. This study focuses on the translation, cultural adaptation, and psychometric evaluation of the Arabic version of the GHBQ to ensure its relevance and accuracy for Arabic-speaking older adults individuals.
Methods
This cross-sectional study was conducted at the Cairo University Educational Hospital’s outpatient clinic. The GHBQ was translated and culturally adapted through a systematic process, including initial translation, back-translation, expert review, and pilot testing. The psychometric properties of the Arabic-translated GHBQ were evaluated using a sample of 200 older adults Arabic-speaking participants. Reliability was assessed using Cronbach’s alpha (α) and Intraclass Correlation Coefficient (ICC). Validity was evaluated through Content Validity Index (CVI), Exploratory Factor Analysis (EFA), and Confirmatory Factor Analysis (CFA).
Results
The Arabic GHBQ demonstrated excellent reliability with Cronbach’s alpha values ranging from 0.74 to 0.87 across subscales and ICC values confirming reproducibility (ICC = 0.82). The CVI indicated strong content validity (average CVI = 0.91). EFA revealed a five-factor structure, explaining 72% of the variance, with all factor loadings exceeding 0.60. CFA supported the questionnaire’s structure with fit indices meeting recommended criteria: χ²/df = 2.05, NFI = 0.92, TLI = 0.94, GFI = 0.90, SRMR = 0.05, AIC = 140.35, and BIC = 160.22. Criterion validity was confirmed through significant correlations with established health behavior measures (r = 0.63, p < 0.001).
Conclusions
The culturally adapted Arabic version of the GHBQ is a reliable and valid tool for assessing health behaviors in the older adults population in Egypt. This instrument can aid healthcare providers in identifying and addressing health behaviors, ultimately improving the well-being of this demographic. Future research should focus on expanding the sample and comparing the GHBQ with other similar tools used in Arabic-speaking populations.
... A cut-point of ≥ 4 is considered as an indicator of frailty. The psychometric properties of GFI have been sufficiently validated in both community-dwelling and hospitalized elderly individuals in China, Germany, and the Netherlands [30][31][32][33]. ...
Background
To determine whether frailty can predict prolonged postoperative ileus (PPOI) in older abdominal surgical patients; and to compare predictive ability of the FRAIL scale, the five-point modified frailty index (mFI-5) and Groningen Frailty Indicator (GFI) for PPOI.
Methods
Patients (aged ≥ 65 years) undergoing major abdominal surgery at our institution between April 2022 to January 2023 were prospectively enrolled. Frailty was evaluated with FRAIL, mFI-5 and GFI before operation. Data on demographics, comorbidities, perioperative management, postoperative recovery of bowel function and PPOI occurrence were collected.
Results
The incidence of frailty assessed with FRAIL, mFI-5 and GFI was 18.2%, 38.4% and 32.5% in a total of 203 patients, respectively. Ninety-five (46.8%) patients experienced PPOI. Time to first soft diet intake was longer in patients with frailty assessed by the three scales than that in patients without frailty. Frailty diagnosed by mFI-5 [Odds ratio (OR) 3.230, 95% confidence interval (CI) 1.572–6.638, P = 0.001] or GFI (OR 2.627, 95% CI 1.307–5.281, P = 0.007) was related to a higher risk of PPOI. Both mFI-5 [Area under curve (AUC) 0.653, 95% CI 0.577–0.730] and GFI (OR 2.627, 95% CI 1.307–5.281, P = 0.007) had insufficient accuracy for the prediction of PPOI in patients undergoing major abdominal surgery.
Conclusions
Elderly patients diagnosed as frail on the mFI-5 or GFI are at an increased risk of PPOI after major abdominal surgery. However, neither mFI-5 nor GFI can accurately identify individuals who will develop PPOI.
Trial registration
This study was registered in Chinese Clinical Trial Registry (No. ChiCTR2200058178). The date of first registration, 31/03/2022, https://www.chictr.org.cn/.
... Furthermore, the Chinese version of the GFI was strongly correlated with the Frailty Index, which is different from our study using the FPFP scale for validation. The Chinese version Table 3 The inter-rater and intra-rater reliability of every item and total score of Groningen frailty indicator of GFI has also good internal consistency (Cronbach's alpha = 0.64) [26]. The Romanian version of GFI is a feasible and valid instrument to assess frailty (Cronbach's alpha = 0.746) [27]. ...
Background
Frailty is an important geriatric syndrome that can be seen as a way of recognizing and distinguishing the complex health conditions of older people. Due to the time limitation, short and simple instruments are most feasible in clinical practice, and several quick screening tools have been developed and validated, Groningen frailty indicator (GFI) is one of these scales. We aimed to validate and evaluate the reliability of the GFI in outpatient older adults in the Turkish population.
Methods
A total of 101 older patients were enrolled to the study. GFI was scored by a geriatrician for every patient at first admission to the geriatric outpatient clinic. Fried Physical Frailty Phenotype (FPFP) was performed as a reference test.
Results
The median age (IQR) was 72.0 (10.0) and 62.4% of the study population (n = 63) was female. Based on the GFI, 34 patients (33.7%) were defined as robust, and 67 patients (66.3%) were defined as living with frailty. There was a statistically significant concordance between GFI and FPFP (Cohen’s kappa: 0.415 p < 0.001). GFI had excellent consistency in inter-rater reliability (Cronbach’s alpha: 0.99, 95% CI 0.97-1.00) and in intra-rater reliability (Cronbach’s alpha: 0.99, 95% CI 0.96-1.0).
Conclusion
Our study showed that GFI is a valid and reliable scale in the Turkish older population.
... Compared with Western countries, research in the field of frailty started at a later stage in China and mainly focused on older community dwellers [19]. It has been reported in recent studies that the prevalence of frailty among Chinese community residents aged 60 and older, with the results ranging from 38.6 to 60.5% based on the GFI criterion [18,20]. A meta-analysis by He et al. [21] showed that being female, increasing age, ADL disability, and developing three or more chronic diseases were risk factors for frailty in older community dwellers. ...
Background
Frailty is emerging as an important determinant for health. Compared with Western countries, research in the field of frailty started at a later stage in China and mainly focused on older community dwellers. Little is known about frailty in Chinese cancer patients, nor the risk factors of frailty. This study aimed at investigating the prevalence of frailty and its risk factors in elderly inpatients with gastric and colorectal cancer.
Methods
This cross-sectional study was conducted at a tertiary hospital in China from Mar. 2020 to Nov. 2020. The study enrolled 265 eligible inpatients aged 60 and older with gastric and colorectal cancer who underwent surgery. Demographic and clinical characteristics, biochemical laboratory parameters, and anthropometric data were collected from all patients. The Groningen Frailty Indicator was applied to assess the frailty status of patients. A multivariate logistic regression model analysis was performed to identify the risk factors of frailty and to estimate their 95% confidence intervals.
Results
The prevalence of frailty in elderly inpatients with gastric and colorectal cancer was 43.8%. A multivariate logistic regression analysis showed that older age (OR = 1.065, 95% CI: 1.001–1.132, P = 0.045), low handgrip strength (OR = 4.346, 95% CI: 1.739–10.863, P = 0.002), no regular exercise habit (OR = 3.228, 95% CI: 1.230–8.469, P = 0.017), and low MNA-SF score (OR = 11.090, 95% CI: 5.119–24.024, P < 0.001) were risk factors of frailty.
Conclusions
This study suggested a relatively high prevalence of frailty among elderly inpatients with gastric and colorectal cancer. Older age, low handgrip strength, no regular exercise habit, and low MNA-SF score were identified as risk factors of frailty.
... Compared with Western countries, research in the eld of frailty started at a later stage in China and mainly focused on older community dwellers [19]. Recent studies have reported that the prevalence of frailty among Chinese community residents aged 60 and older, ranged from 38.6-60.5% based on the GFI criterion [18,20]. A meta-analysis by He et al [21] showed that being female, increasing age, ADL disability, and developing three or more chronic diseases were risk factors for frailty in older community dwellers. ...
Background
Frailty is emerging as an important determinant for health. Compared with Western countries, research in the field of frailty started at a later stage in China and mainly focused on older community dwellers. Little is known about frailty in Chinese cancer patients, nor the risk factors of frailty. This study aimed to investigate the prevalence of frailty and its risk factors in elderly inpatients with gastrointestinal cancer. Methods
This cross-sectional study was performed at a tertiary hospital in China from Mar. 2020 to Nov. 2020. The study enrolled 265 inpatients aged 60 and older with gastrointestinal cancer who underwent surgery. The demographic and clinical characteristics, biochemical laboratory parameters, and anthropometric data were collected from all patients. The Groningen Frailty Indicator was applied to assess the frailty status of patients. Multivariate logistic regression model analysis was carried out to identify risk factors of frailty and estimate their 95% confidence intervals. ResultsThe prevalence of frailty in elderly inpatients with gastrointestinal cancer was 43.8%. A multivariate logistic regression analysis showed that older age (OR=1.065, 95% CI: 1.001-1.132, P =0.045), low handgrip strength (OR=4.346, 95% CI: 1.739-10.863, P =0.002), no regular exercise habit (OR=3.228, 95% CI: 1.230-8.469, P =0.017), and low MNA-SF score (OR=11.090, 95% CI: 5.119-24.024, P <0.001) were risk factors of frailty. ConclusionsThis study suggested that the prevalence of frailty was high among elderly inpatients with gastrointestinal cancer. Older age, low handgrip strength, no regular exercise habit, and low MNA-SF score were identified as risk factors of frailty.
... Compared with western countries, researches in the eld of frailty started at a later stage in China and mainly focused on community elderly dwellers [24]. Two recent studies have reported that the prevalence of frailty among Chinese community residents aged 60 and older, ranged from 38.6-60.5% based on the GFI criterion [23,25]. Being female, increasing age, ADL disability, and developing three or more chronic diseases were risk factors for frailty in this group [26]. ...
Background
Frailty is emerging as an important determinant for health, while researches in the field of frailty start at a later stage in China and mainly focuses on community elderly dwellers. Little is known about frailty in cancer patients in China, nor the risk factors of frailty. This study aimed to investigate the prevalence of frailty and its risk factors in elderly inpatients with gastrointestinal cancer.
Methods
This cross-sectional study was performed at a tertiary hospital in China from Mar. 2020 to Nov. 2020. The study enrolled 265 inpatients aged 60 and older with gastrointestinal cancer who successfully underwent surgery. The demographic and clinical characteristics, biochemical laboratory parameters, and anthropometric data were collected from all patients. The Groningen Frailty Indicator was applied to assess patients’ frailty status. Multivariate logistic regression model analysis was carried out to identify risk factors of frailty and estimate their 95% confidence intervals.
Results
The prevalence of frailty in elderly inpatients with gastrointestinal cancer was 43.8%. A multivariate logistic regression analysis showed that older age (OR = 1.065, 95% CI: 1.001–1.132, P = 0.045), low handgrip strength (OR = 4.346, 95% CI: 1.739–10.863, P = 0.002), no regular exercise habit (OR = 3.228, 95% CI: 1.230–8.469, P = 0.017), and low MNA-SF score (OR = 11.090, 95% CI: 5.119–24.024, P < 0.001) were risk factors of frailty.
Conclusions
This study suggested that the prevalence of frailty was high among elderly inpatients with gastrointestinal cancer. Older age, low handgrip strength, no regular exercise habit, and low MNA-SF score were risk factors of frailty.
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.
Purpose
The quick aphasia battery (QAB) was designed to evaluate language disorder from multi-dimension efficiently, which had been translated into several languages but lacked in Chinese. This study conducted cross-cultural adaption for the Chinese version and verified its psychometric properties.
Material and Methods
First, the Chinese Version of quick aphasia battery (CQAB) was adapted following WHO literature guidelines with steps of forward translation, expert panel, back-translation, pre-test, and interview, then develop the final version. Second, the psychometric properties tests were conducted in 128 post-stroke patients to identify if aphasia happens and verify the validity and reliability of CQAB.
Results
The Cronbach’s alpha coefficient of the CQAB is 0.962, test–retest reliability 0.849, and inter-rater reliability 0.998. Content validity 0.917, KMO 0.861, exploratory factor analysis extracted 2 factors named “language understanding” and “language program”, cumulative variance contribution rate is 91.588% >50%. Calibration association validity 0.977. Sensitivity 0.977, specificity 0.932, with the optimal cutoff point is 8.86.
Conclusion
The study supported CQAB, which adapted following standardized guidelines, is reliable and effective to assess language impairment in post-stroke patients.
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.
Background
While community-based eldercare has proven to be effective in qualitative studies, there is limited evidence on the effectiveness of this geriatric care model in rural communities where caring for older people is traditionally the responsibility of family members, but a formal long-term care was recently introduced in China. CIE is a rural community-embedded intervention using multidisciplinary team, to provide evidenced-based integrated care services for frail older people including social care services and allied primary healthcare and community-based rehabilitation services.
Methods
CIE is a prospective stepped-wedge cluster randomized trial conducted at 5 community eldercare centers in rural China. The multifaceted CIE intervention, guided by chronic care model and integrated care model, consists of five components: comprehensive geriatric assessment, individualized care planning, community-based rehabilitation, interdisciplinary case management, and care coordination. The intervention is rolled out in a staggered manner in these clusters of centers at an interval of 1 month. The primary outcomes include functional status, quality of life, and social support. Process evaluation will also be conducted. Generalized linear mixed model is employed for binary outcomes.
Discussion
This study is expected to provide important new evidence on clinical effectiveness and implementation process of an integrated care model for frail older people. The CIE model is also unique as the first registered trial implementing a community-based eldercare model using multidisciplinary team to promote individualized social care services integrated with primary healthcare and community-based rehabilitation services for frail older people in rural China, where formal long-term care was recently introduced.
Trial registration {2a}
China Clinical Trials Register (http://www.chictr.org.cn/historyversionpub.aspx?regno=ChiCTR2200060326). May 28th, 2022.
Objectives:
To identify the role of frailty, social networks, and depression in self-neglect in an older Chinese population.
Methods:
The study was conducted in 521 older adults recruited from four community healthcare centers in a district in Beijing, China. Participants were investigated by a set of questionnaires.
Results:
Frailty (β=0.150, p=0.759) was not associated with self-neglect of older adults. Social isolation (β=1.980, p<0.001) and depression (β=3.606, p<0.001) were both factors associated with self-neglect in older adults.
Conclusion:
Management of depression and improvement of social networks of older adults should be incorporated into interventional strategies to effectively control self-neglect. Understanding self-neglect and its associated factors will ultimately contribute to the intervention development and well-being of older adults.
Objective
To determine the associations between four validated multidimensional self-report frailty scales and nine indices of oral health in community-dwelling older persons.
Materials and Methods
This pilot study was conducted in a sample of 208 older persons aged 70 years and older who visited two dental practices in the Netherlands. Frailty status was measured by four different self-report frailty questionnaires: Tilburg Frailty Indicator (TFI), Groningen Frailty Indicator (GFI), Sunfrail Checklist (SC), and the Sherbrooke Postal Questionnaire (SPQ). Oral health was assessed by two calibrated examiners.
Results
The prevalence of frailty according to the four frailty measures TFI, GFI, SC, and SPQ was 32.8%, 31.5%, 24.5%, and 49.7%, respectively. The SC correlated with four oral health variables (DMFT, number of teeth, percentage of occlusal contacts, Plaque Index), the TFI with three (number of teeth, percentage of occlusal contacts, Plaque Index), the GFI only with DPSI, and the SPQ with the number of teeth and the number of occlusal contacts.
Conclusion
Of the studied multidimensional frailty scales, the SC and TFI were correlated with most oral health variables (four and three, respectively). However, it should be noticed that these correlations were small.
Clinical relevance
The SC and TFI might help to identify older people with risk of poor oral health so that preventive care can be used to ensure deterioration of oral health and maintenance of quality of life. Vice versa early detection of frailty by oral care professionals could contribute to interprofessional management of frailty.
This study aimed to examine the validity and reliability of the Persian Version of the Comprehensive Frailty Assessment Instrument Plus (CFAI-Plus) among community-dwelling older adults. It was completed by 340 older adults ≥60 years. The content and face validity were confirmed based on the opinion of the target group and experts. In the exploratory factor analysis, seven factors were extracted, explaining 62.8% of the total variance. Confirmatory factor analysis showed acceptable fit indices (Root Mean Square Error of Approximation = 0.045; Comparative Fit Index = 0.93; Tucker-Lewis Index = 0.92). Internal consistency was adequate for factors (Cronbach's alpha: range 0.47 to 0.88), and the test-retest reliability was acceptable (intra-class correlation coefficient: range 0.76 to 0.92). A higher CFAI-Plus score were found in those who were older, female, less-educated, single, lived alone, and had inadequate income. This study supports the reliability and validity of the Persian CFAI-Plus in community-dwelling older adults.
This study aimed to investigate the status of caregiver burden among informal caregivers of hospitalized frail older patients and explore the associated factors. A total of 191 frail older patients and their informal caregivers were recruited from the inpatient units of the three teaching hospitals. We collected data using the FRAIL scale, the Zarit Burden Interview, and the Simplified Coping Style Questionnaire. We used descriptive statistics, Pearson correlation coefficients, one-way analysis of variance, and multiple linear regression for the data analysis. The caregivers of hospitalized frail older patients experienced a moderate caregiver burden (26.476±11.289). The regression model for caregiver burden was significant. Male caregivers, taking care of patients before hospitalization, experiencing negative emotions, and negative coping styles were significantly associated with caregiver burden, F (7, 183) = 15.13, p <. 001. The findings suggest that early identification of caregiver burden and focused interventions for alleviating caregiver burden are needed.
Background
Frailty becomes a great challenge with population aging. The proactive identification of frailty is considered as a rational solution in the community. Previous studies found that frailty instruments had insufficient predictive accuracy for adverse outcomes, but they mainly focused on long-term outcomes and constructed frailty instruments based on available data not original forms. The predictive performance of original frailty instruments for short-term outcomes in community-dwelling older adults remains unknown.
Objective
To examine the predictive performance of seven frailty instruments in their original forms for 1-year incident outcomes among community-dwelling older adults.
Design
A prospective cohort study.
Settings
A total of 22 communities were selected by a stratified sampling method from one Chinese city.
Participants
A total of 749 older adults aged ≥ 60 years (mean age of 69.2 years, 69.8% female) were followed up after 1 year.
Methods
Baseline frailty was assessed by three purely physical dimensional instruments (i.e. Frailty Phenotype, the Study of Osteoporotic Fracture and FRAIL Scale) and four multidimensional instruments (i.e. Frailty Index, Groningen Frailty Indicator, Tilburg Frailty Indicator and Comprehensive Frailty Assessment Instrument), respectively. Outcomes included incident disability, falls, hospitalization and the combined outcome at 1-year follow-up. The receiver operating characteristic curves were plotted to assess the predictive performance of frailty instruments.
Results
The areas under the curves of seven frailty instruments in predicting incident outcomes ranged from 0.55 [95% confidence interval (CI): 0.51-0.60] to 0.67 (95% CI: 0.61-0.72), with high specificity (72.3%-99.2%) and low sensitivity (4.0%-49.6%). Four multidimensional instruments had much higher sensitivity (20.9%-49.6% versus 4.0%-11.7%) than three purely physical dimensional instruments. Overall, the Frailty Index was more accurate than some instruments in predicting incident outcomes, while several self-report instruments had comparable predictive accuracy to the Frailty Index for all (FRAIL Scale) or some (Groningen Frailty Indicator and Tilburg Frailty Indicator) of the incident outcomes.
Conclusions
All frailty instruments have inadequate predictive accuracy for short-term outcomes among community-dwelling older adults. The Frailty Index roughly performs better but self-report instruments are comparable to the Frailty Index for all or some of the outcomes. An accurate frailty instrument needs to be developed, and the simple self-report instruments could be used temporarily as practical and efficient tools in primary care.
Although geriatric research in general has increased in recent years, there is no effective treatment for frailty. Among older adults, those with frailty have an increased risk of falls, disability, and death. The population of older adults has increased rapidly in China, and resulting in an increased demand for medical care services for older adults, including those with frailty. However, much of the research on frailty has been conducted in Europe and the United States, and European and American standards for frailty are not always applicable to Chinese individuals. Clinicians and researchers in China have shown increasing interest in frailty in recent years. Here, we reviewed the current state of frailty research in China.
We aimed to compare the diagnostic test accuracy (DTA) of six frailty screening tools against comprehensive geriatric assessment (CGA) in the community. A total of 1177 community-dwelling older people were recruited. Frailty was assessed by purely physical tools including Physical Frailty Phenotype (PFP), FRAIL (fatigue, resistance, ambulation, illness and loss of weight), Study of Osteoporotic Fracture (SOF), and multidimensional tools including Tilburg Frailty Indicator (TFI), Groningen Frailty Indicator (GFI) and Comprehensive Frailty Assessment Instrument (CFAI). The receiver operating characteristic curve analyses were performed. The GFI, TFI and CFAI [areas under the curve (AUCs): 0.78-0.80] had better diagnostic accuracy than SOF, PFP and FRAIL (AUCs: 0.69-0.72) (χ2: 6.37-26.76, P<.05). The optimal cut-offs for the PFP, FRAIL and SOF were identical to their original prefrail cut-offs. These results implicate that the multidimensional tools are more effective to identify frailty in the whole community setting, while the self-report FRAIL may be used to identify the prefrail and facilitate early interventions particularly in the community setting with adequate healthcare resources.
Objective (s): Assessing the disability of the elderly requires a specific instrument. The Groningen Frailty Inventory is one of
the known instruments that used to measure the ability of the elderly. The present study aimed to translate and initially validate
the Persian version of the GFI questionnaire.
Methods: The present study was a methodological study which was performed on 139 elderly people. The questionnaire was
translated from English into Persian and face and content validity were determined qualitatively. The quantitative validation
was performed using construct validity (known groups comparison and concurrent validity). The General Anxiety Inventory
was used for concurrent validity. Reliability was assessed by estimating internal consistency and test-retest analyses.
Results: The results of the known groups analysis showed that the questionnaire well differentiated disability score in older
men versus women as hypothesized. Older people with lower education also had lower score as compared to well-educated
older participants. Concurrent validity indicated a significant correlation between the Persian version of the Groningen Frailty
and the General Anxiety Inventory. The internal consistency (Kuder- Richardson) was 0.762. Test-retest reliability (ICC) of the
questionnaire with a two-weeks interval was 0.61.
Conclusion: The findings indicated that the Persian version of Groningen Frailty Indicator is a valid instrument and now could
be used for measuring in research and clinical practice. It is suggested that the future studies assess the structural validity of the
GFI using factor analysis with a bigger sample size.
The relationship between physical disability and depressive symptoms has been associated with social support. Different aspects of social support may play distinct roles in health-related quality of life. The aim of this study was to examine the mediation of social support in the relationship between physical disability and depressive symptoms among old people in Mainland China. Subjective support and utilization of support mediated the relationship between ADL and depressive symptoms, with the indirect effect of subjective support and utilization of support at 0.038 and 0.030 respectively (the total effect was 0.180). Subjective support was negatively associated with depressive symptoms in independent elderly people, utilization of support was negatively associated with depressive symptoms in partially dependent elderly people, and utilization of support had a greater association with geriatric depressive symptoms than subjective support in severely dependent elderly people. Social support mechanism and positive psychological intervention should be established and introduced in accordance with the physical disability of the elderly people, to protect them from depressive symptoms.
In elderly populations, frailty is associated with higher mortality risk. Although many frailty scores (FS) have been proposed, no single score is considered the gold standard. We aimed to evaluate the agreement between a wide range of FS in the English Longitudinal Study of Ageing (ELSA). Through a literature search, we identified 35 FS that could be calculated in ELSA wave 2 (2004-2005). We examined agreement between each frailty score and the mean of 35 FS, using a modified Bland-Altman model and Cohen's kappa (κ). Missing data were imputed. Data from 5,377 participants (ages ≥60 years) were analyzed (44.7% men, 55.3% women). FS showed widely differing degrees of agreement with the mean of all scores and between each pair of scores. Frailty classification also showed a very wide range of agreement (Cohen's κ = 0.10-0.83). Agreement was highest among "accumulation of deficits"-type FS, while accuracy was highest for multidimensional FS. There is marked heterogeneity in the degree to which various FS estimate frailty and in the identification of particular individuals as frail. Different FS are based on different concepts of frailty, and most pairs cannot be assumed to be interchangeable. Research results based on different FS cannot be compared or pooled.
Background.:
Frailty is an age-related clinical syndrome of decreased resilience to stressors and is associated with numerous adverse outcomes. Although there is preponderance of literature on frailty in developed countries, limited investigations have been conducted in less developed regions including China-a country that has the world's largest aging population. We examined frailty prevalence in China by socio-demographics and geographic region, and investigated correlates of frailty.
Methods.:
Participants were 5301 adults aged ≥60 years from the China Health and Retirement Longitudinal Study. Frailty was identified by the validated physical frailty phenotype (PFP) scale. We estimated frailty prevalence in the overall sample and by socio-demographics. We identified age-adjusted frailty prevalence by geographical region. Bivariate associations of frailty with health and function measures were evaluated by chi-squared test and analysis of variance.
Results.:
We found 7.0% of adults aged ≥60 years were frail. Frailty is more prevalent at advanced ages, among women, and persons with low education. Age-adjusted frailty prevalence ranged from 3.3% in the Southeast and the Northeast to 9.1% in the Northwest, and was >1.5 times higher in rural vs. urban areas. Frail vs. nonfrail persons had higher prevalence of comorbidities, falls, disability, and functional limitation.
Conclusions.:
We demonstrated the utility of the PFP scale in identifying frail Chinese elders, and found substantial socio-demographic and regional disparities in frailty prevalence. The PFP scale may be incorporated into clinical practice in China to identify the most vulnerable elders to reduce morbidity, prevent disability, and enable more efficient use of healthcare resources.
Background . The predictive value of frailty assessment is still debated. We analyzed the predictive value of frailty of independent living elderly. The outcomes variables were visits to the general practitioner, hospital admission, and occurrence of new health problems. Methods . A one-year follow-up study was executed among 215 community-living old Romanians. General practitioners reported the outcome variables of patients, whose frailty was assessed one year before, using the Groningen Frailty Indicator. The predictive validity is analyzed by descriptive and regression analysis. Results . Three-quarters of all participants visited their general practitioner three times more last year and one-third were at least once admitted to a hospital. Patients who scored frail one year before were more often admitted to a hospital. Visits to the general practitioner and occurrence of new health problems were not statistically significant related to frailty scores. The frailty items polypharmacy, social support, and activities in daily living were associated with adverse outcomes. Conclusions . The predictive value of frailty instruments as the Groningen Frailty Indicator is still limited. More research is needed to predict health outcomes, health care utilization, and quality of life of frailty self-assessment instruments. Validation research on frailty in different “environments” is recommended to answer the question to what extent contextual characteristics influence the predictive value.
One of the leading causes of morbidity and premature mortality in older people is frailty. Frailty occurs when multiple physiological systems decline, to the extent that an individual's cellular repair mechanisms cannot maintain system homeostasis. This review gives an overview of the definitions and measurement of frailty in research and clinical practice, including: Fried's frailty phenotype; Rockwood and Mitnitski's Frailty Index (FI); the Study of Osteoporotic Fractures (SOF) Index; Edmonton Frailty Scale (EFS); the Fatigue, Resistance, Ambulation, Illness and Loss of weight (FRAIL) Index; Clinical Frailty Scale (CFS); the Multidimensional Prognostic Index (MPI); Tilburg Frailty Indicator (TFI); PRISMA-7; Groningen Frailty Indicator (GFI), Sherbrooke Postal Questionnaire (SPQ); the Gérontopôle Frailty Screening Tool (GFST) and the Kihon Checklist (KCL), among others. We summarise the main strengths and limitations of existing frailty measurements, and examine how well these measurements operationalise frailty according to Clegg's guidelines for frailty classification — that is: their accuracy in identifying frailty; their basis on biological causative theory; and their ability to reliably predict patient outcomes and response to potential therapies.
Background: over the years a plethora of frailty assessment tools has been developed. These instruments can be basically grouped into unidimensional, based on the physical-biological dimension, and multidimensional conceptualization, based on the connections among the physical, psychological, and social domains. At now, studies on the comparison between uni- and multidimensional frailty measures are limited. Objective: the aims of this paper were: i) to compare the prevalence of frailty obtained using a uni- and multidimensional measure; ii) to analyze differences in the functional status among individuals captured as frail or robust by the two measures; iii) to investigate relations between the two frailty measures and disability. Methods: 267 community-dwelling older adults (73.4±6 years old, 59.9% of women) participated in this cross-sectional study. The Cardiovascular Health Study (CHS) index and the Tilburg Frailty Indicator (TFI) were used to measure frailty in a uni- and multidimensional way, respectively. The International Physical Activity Questionnaire, the Center of Epidemiologic Studies Depression scale, and the Loneliness Scale were administered to evaluate the functional status. Disability was assessed using the Groningen Activity Restriction Scale (GARS). Data were treated with descriptive statistics, one-way analysis of variance, correlations, and ROC analyses through the evaluation of the areas under the curve (AUC). Results: results showed that frailty prevalence rate is strictly dependent by the index used (CHS=12.7%; TFI= 44.6%). Furthermore, frail individuals presented differences in terms of functional status in all the domains. Frailty measures were significantly correlated each other (r=.483), and with disability (CHS: r=.423; TFI: r=.475). Lastly, the AUC of the TFI (.833) for disability was higher with respect to the one of CHS (.770). Conclusion: data reported here confirm that different instruments capture different frail individuals. Clinicians and researchers have to consider the different ability of the two measures to detect frail individuals.
Background:
Primary health care may play an important role in identifying persons at risk for frailty. The Groningen Frailty Indicator (GFI) is considered a valid instrument to assess frailty in old age. However, it is not tested yet in a different cultural context. The aim of this study is to analyse the construct, content and criterion validity of the GFI in independent-living old Romanians.
Methods:
Twenty-two GPs participated in this study. They have sent he GFI questionnaire to 215 patients of 65 years and over. The GPs assessed the frailty of the patients, independently from the questionnaire.
Results:
The mean age of the respondents was 74.9 years. The mean GFI score was 5.5 (SD 2.9). Three-quarters of the respondents fit into the 'moderate' or 'severe' frailty category. Citizens 80 years old and older scored higher in terms of frailty. Ninety-eight per cent of the respondents completed at least 75% of the GFI items. The construct validity was good (Cronbach's alpha 0.746). All the items contributed statistically significant to the total GFI score (content validity). The old citizens who were rated as frail by the GPs (criterion validity) had a higher GFI score
Conclusion:
This study showed the GFI to be a feasible and valid instrument to assess frailty in independent-living old Romanians. Compared with the Dutch old, the prevalence of frailty in independently living old Romanians is high. Further research is needed to determine the appropriate cut-off points in the GFI scores in different care systems.
Due to the rapidly increasing number of older people worldwide, the prevalence of frailty among older adults is expected to escalate in coming decades. It is crucial to recognize early onset symptoms to initiate specific preventive care. Therefore, early detection of frailty with appropriate screening instruments is needed. The aim of this study was to evaluate the underlying dimensionality of the Groningen Frailty Indicator (GFI), a widely used self-report screening instrument for identifying frail older adults. In addition, criterion validity of GFI subscales was examined and composition of GFI scores was evaluated.
A cross-sectional study design was used to evaluate the structural validity, internal consistency and criterion validity of the GFI questionnaire in older adults aged 65 years and older. All subjects completed the GFI questionnaire (n = 1508). To assess criterion validity, a smaller sample of 119 older adults completed additional questionnaires: De Jong Gierveld Loneliness Scale, Hospital Anxiety Depression Scale, RAND-36 physical functioning, and perceived general health item of the EuroQol-5D. Exploratory factor analysis and Mokken scale analysis were used to evaluate the structural validity of the GFI. A Venn diagram was constructed to show the composition of GFI subscale scores for frail subjects.
The factor structure of the GFI supported a three-dimensional structure of the scale. The subscales Daily Activities and Psychosocial Functioning showed good internal consistency, scalability, and criterion validity (Daily Activities: Cronbach's alpha = 0.81, Hs = .84, r = -.62; Psychosocial Functioning: Cronbach's alpha = 0.80, Hs = .35, r = -.48). The subscale Health Problems showed less strong internal consistency but acceptable scalability and criterion validity (Cronbach's alpha = .57, Hs = .35, r = -.48). The present data suggest that 90% of the frail older adults experience problems in the Psychosocial Functioning domain.
The present findings support a three-dimensional factor structure of the GFI, suggesting that a multidimensional assessment of frailty with the GFI is possible. These GFI subscale scores produce a richer assessment of frailty than with a single overall sum GFI score, and likely their use will contribute to more directed and customized care for older adults.
"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)
Background:
many instruments are available to identify frail older adults who may benefit from geriatric interventions. Most of those instruments are time-consuming and difficult to use in primary care.
Objective:
to select a valid instrument to identify frail older adults in primary care, five simple instruments were compared.
Methods:
instruments included clinical judgement of the general practitioner, prescription of multiple medications, the Groningen frailty indicator (GFI), PRISMA-7 and the self-rated health of the older adult. Fried's frailty criteria and a clinical judgement by a multidisciplinary expert panel were used as reference standards. Data were used from the cross-sectional Dutch Identification of Frail Elderly Study consisting of 102 people aged 65 and over from a primary care practice in Amsterdam. In this study, frail older adults were oversampled. We estimated the accuracy of each instrument by calculating the area under the ROC curve. The agreement between the instruments and the reference standards was determined by kappa.
Results:
frailty prevalence rates in this sample ranged from 11.6 to 36.4%. The accuracy of the instruments ranged from poor (AUC = 0.64) to good (AUC = 0.85).
Conclusion:
PRISMA-7 was the best of the five instruments with good accuracy. Further research is needed to establish the predictive validity and clinical utility of the simple instruments used in this study.
If brief and easy to use self report screening tools are available to identify frail elderly, this may avoid costs and unnecessary assessment of healthy people. This study investigates the predictive validity of three self-report instruments for identifying community-dwelling frail elderly.
This is a prospective study with 1-year follow-up among community-dwelling elderly aged 70 or older (n = 430) to test sensitivity, specificity, and positive and negative predicted values of the Groningen Frailty Indicator, Tilburg Frailty Indicator and Sherbrooke Postal Questionnaire on development of disabilities, hospital admission and mortality. Odds ratios were calculated to compare frail versus non-frail groups for their risk for the adverse outcomes.
Adjusted odds ratios show that those identified as frail have more than twice the risk (GFI, 2.62; TFI, 2.00; SPQ, 2,49) for developing disabilities compared to the non-frail group; those identified as frail by the TFI and SPQ have more than twice the risk of being admitted to a hospital. Sensitivity and specificity for development of disabilities are 71% and 63% (GFI), 62% and 71% (TFI) and 83% and 48% (SPQ). Regarding mortality, sensitivity for all tools are about 70% and specificity between 41% and 61%. For hospital admission, SPQ scores the highest for sensitivity (76%).
All three instruments do have potential to identify older persons at risk, but their predictive power is not sufficient yet. Further research on these and other instruments is needed to improve targeting frail elderly.
Frailty is highly prevalent in older people. Its serious adverse consequences, such as disability, are considered to be a public health problem. Therefore, disability prevention in community-dwelling frail older people is considered to be a priority for research and clinical practice in geriatric care. With regard to disability prevention, valid screening instruments are needed to identify frail older people in time. The aim of this study was to evaluate and compare the psychometric properties of three screening instruments: the Groningen Frailty Indicator (GFI), the Tilburg Frailty Indicator (TFI) and the Sherbrooke Postal Questionnaire (SPQ). For validation purposes the Groningen Activity Restriction Scale (GARS) was added.
A questionnaire was sent to 687 community-dwelling older people (> or = 70 years). Agreement between instruments, internal consistency, and construct validity of instruments were evaluated and compared.
The response rate was 77%. Prevalence estimates of frailty ranged from 40% to 59%. The highest agreement was found between the GFI and the TFI (Cohen's kappa = 0.74). Cronbach's alpha for the GFI, the TFI and the SPQ was 0.73, 0.79 and 0.26, respectively. Scores on the three instruments correlated significantly with each other (GFI - TFI, r = 0.87; GFI - SPQ, r = 0.47; TFI - SPQ, r = 0.42) and with the GARS (GFI - GARS, r = 0.57; TFI - GARS, r = 0.61; SPQ - GARS, r = 0.46). The GFI and the TFI scores were, as expected, significantly related to age, sex, education and income.
The GFI and the TFI showed high internal consistency and construct validity in contrast to the SPQ. Based on these findings it is not yet possible to conclude whether the GFI or the TFI should be preferred; data on the predictive values of both instruments are needed. The SPQ seems less appropriate for postal screening of frailty among community-dwelling older people.
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.
Frailty is considered highly prevalent in old age and to confer high risk for falls, disability, hospitalization, and mortality. Frailty has been considered synonymous with disability, comorbidity, and other characteristics, but it is recognized that it may have a biologic basis and be a distinct clinical syndrome. A standardized definition has not yet been established.
To develop and operationalize a phenotype of frailty in older adults and assess concurrent and predictive validity, the study used data from the Cardiovascular Health Study. Participants were 5,317 men and women 65 years and older (4,735 from an original cohort recruited in 1989-90 and 582 from an African American cohort recruited in 1992-93). Both cohorts received almost identical baseline evaluations and 7 and 4 years of follow-up, respectively, with annual examinations and surveillance for outcomes including incident disease, hospitalization, falls, disability, and mortality.
Frailty was defined as a clinical syndrome in which three or more of the following criteria were present: unintentional weight loss (10 lbs in past year), self-reported exhaustion, weakness (grip strength), slow walking speed, and low physical activity. The overall prevalence of frailty in this community-dwelling population was 6.9%; it increased with age and was greater in women than men. Four-year incidence was 7.2%. Frailty was associated with being African American, having lower education and income, poorer health, and having higher rates of comorbid chronic diseases and disability. There was overlap, but not concordance, in the cooccurrence of frailty, comorbidity, and disability. This frailty phenotype was independently predictive (over 3 years) of incident falls, worsening mobility or ADL disability, hospitalization, and death, with hazard ratios ranging from 1.82 to 4.46, unadjusted, and 1.29-2.24, adjusted for a number of health, disease, and social characteristics predictive of 5-year mortality. Intermediate frailty status, as indicated by the presence of one or two criteria, showed intermediate risk of these outcomes as well as increased risk of becoming frail over 3-4 years of follow-up (odds ratios for incident frailty = 4.51 unadjusted and 2.63 adjusted for covariates, compared to those with no frailty criteria at baseline).
This study provides a potential standardized definition for frailty in community-dwelling older adults and offers concurrent and predictive validity for the definition. It also finds that there is an intermediate stage identifying those at high risk of frailty. Finally, it provides evidence that frailty is not synonymous with either comorbidity or disability, but comorbidity is an etiologic risk factor for, and disability is an outcome of, frailty. This provides a potential basis for clinical assessment for those who are frail or at risk, and for future research to develop interventions for frailty based on a standardized ascertainment of frailty.
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.
Many definitions of frailty exist, but few have been directly compared. We compared the relationship between a definition of frailty based on a specific phenotype with one based on an index of deficit accumulation.
The data come from all 2305 people 70 years old and older who composed the clinical examination cohort of the second wave of the Canadian Study of Health and Aging. We tested convergent validity by correlating the measures with each other and with other health status measures, and analyzed cumulative index distributions in relation to phenotype. To test criterion validity, we evaluated survival (institutionalization and all-cause mortality) by frailty index (FI) score, stratified by the phenotypic definitions as "robust," "pre-frail," and "frail."
The measures correlated moderately well with each other (R=0.65) and with measures of function (phenotypic definition R=0.66; FI R=0.73) but less well with cognition (phenotypic definition R=-0.35; FI R=-0.58). The median FI scores increased from 0.12 for the robust to 0.30 for the pre-frail and 0.44 for the frail. Survival was also lower with increasing frailty, and institutionalization was more common, but within each phenotypic class, there were marked differences in outcomes based on the FI values-e.g., among robust people, the median 5-year survival for those with lower FI values was 85%, compared with 55% for those with higher FI values.
The phenotypic definition of frailty, which offers ready clinical operationalization, discriminates broad levels of risk. The FI requires additional clinical translation, but allows the risk of adverse outcomes to be defined more precisely.
Objective
To systematically assess the prevalence of frailty, including prefrailty, stratified prevalence according to frailty criteria, gender, age, and region, and the risk factors for frailty in China.
Design
We conducted a systematic literature review and meta-analysis using articles available in 8 databases including PubMed, Cochrane Library, Web of Science, CINAHL Plus, China Knowledge Resource Integrated Database (CNKI), Wanfang Database, Chinese Biomedical Database (CBM), and Weipu Database (VIP).
Setting
Crosssectional and cohort data from Chinese community.
Participants
Community-dwelling adults aged 65 and older.
Measurements
Two authors independently extracted data based upon predefined criteria. Where data were available we conducted a meta-analysis of frailty parameters using a random-effects model.
Results
We screened 915 different articles, and 14 studies (81258 participants) were ultimately included in this analysis. The prevalence of frailty and prefrailty in individual studies varied from 5.9% to 17.4% and from 26.8% to 62.8%, respectively. The pooled prevalence of frailty and prefrailty were 10% (95% CI: 8% to 12%, I2 = 97.4%, P = 0.000) and 43% (95% CI: 37% to 50%, I2 = 98.0%, P = 0.000), respectively. The pooled frailty prevalence was 8% for the Fried frailty phenotype, 12% for the frail index, and 15% for the FRAIL scale. Age-stratified meta-analyses showed the pooled prevalence of frailty to be 6%, 15%, and 25% for those aged 65–74, 75–84, and ≥85 years old, respectively. The pooled prevalence of frailty was 8% for males and 11% for females. The pooled prevalence of frailty in Mainland China, Taiwan, and Hong Kong was 12%, 8%, and 14%, respectively. The pooled frailty prevalence was 10% in urban areas and 7% in rural areas. After controlling for confounding variables, increasing age (OR = 1.28, 95% CI: 1.2 to 1.36, I² = 98.0%, P = 0.000), being female (OR = 1.29, 95% CI: 1.16 to 1.43, I² =92.7%, P=0.000), activities of daily living (ADL) disability (OR = 1.72, 95% CI: 1.57 to 1.90, I² = 99.7%, P = 0.000), and having three or more chronic diseases (OR = 1.97, 95% CI: 1.78 to 2.18, I² = 97.5%, P = 0.000) were associated with frailty.
Conclusions
These findings of this review indicate an overall pooled prevalence of frailty among Chinese community-dwelling older people of 10%. Increasing age, being female, ADL disability, and having three or more chronic diseases were all risk factors for frailty. Further research will be needed to identify additional frailty risk factors in order to better treat and prevent frailty in the community.
Frailty is a geriatric syndrome associated with adverse outcomes such as falls, disability, and mortality. Frailty is common and contributes to rising health care costs. Early screening and timely tailored intervention may effectively prevent or delay the adverse outcomes in older adults. Studies on frailty and its specific measurement tools are increasing in number, but the debate on the screening instruments remains. Currently, self-reported screening tools can identify frailty and predict the risk of adverse outcomes in older adults. Because they are easy to use and quickly provide information, self-reported frailty screening tools have significant implication in primary care settings and clinics. We reviewed the frailty screening instruments in older adults and proposed a two-step pathway for frailty identification, and to manage declines in intrinsic capacity as well as boost resilience.
Frailty is a term that presents many difficulties for policy makers and clinicians due to the lack of consensus in defining frailty in a way that meets the needs of older people. A principle-based concept analysis was used to examine the scientific literature across four perspectives: medicine, nursing, social sciences, and occupational and physiotherapy. The purpose was to identify the conceptual components of frailty as revealed by analysis of the literature, and to develop a theoretical definition of frailty. The findings exposed commonalities in implied meanings both within and across perspectives. The strengths of frailty as a concept are revealed in the implications for clinical practice and relevance to health professionals. The limitations reflect a concept that is still evolving and further research is recommended but this should not stop health professionals engaging in this process. The definition developed in this study will enhance existing knowledge and promote a shared understanding to unite different disciplines in recognising frailty as an important concept.
Pain and frailty are both prevalent and have severe health impacts among older adults. We conducted a cross-sectional observational study to examine the association between pain and frailty, and depression as a mediator and its interaction with pain on frailty among 1788 Chinese community-dwelling older adults. Physical frailty, pain intensity and depressive symptoms were assessed using the Frailty Phenotype, the revised Faces Pain Scale (FPS-R), and the 5-item Geriatric Depression Scale (GDS-5), respectively. We found that both pain (OR = 1.61; 95% CI: 1.32, 1.97) and depressive symptoms (OR = 4.67; 95% CI: 3.36, 6.50) were positively associated with physical frailty (OR = 1.61; 95% CI: 1.32, 1.97), and depressive symptoms were associated with pain (OR = 1.94; 95% CI: 1.15, 3.39), attenuating the association between pain and physical frailty by 56.1%. Furthermore, older adults with both pain and depressive symptoms (OR = 8.13; 95% CI: 5.27, 12.53) had a higher risk of physical frailty than, those with pain (OR = 1.41; 95% CI: 1.14, 1.76) or depressive symptoms (OR = 3.63; 95% CI: 2.25, 5.85) alone. The relative excess risk of interaction (RERI), the attributable proportion due to interaction (AP) and the synergy index (S) were 4.08, 0.50, and 2.34, respectively. These findings suggest that the positive association of pain with frailty is persistent and partially mediated by depression, and comorbid depression and pain has an additive interaction on physical frailty. It has an implication of multidisciplinary care for frail older adults with pain.
Background:
Routine screening for frailty could be used to timely identify older people with increased vulnerability und corresponding medical needs.
Objective:
The aim of this study was the translation and cross-cultural adaptation of the PRISMA-7 questionnaire, the FRAIL scale and the Groningen Frailty Indicator (GFI) into the German language as well as a preliminary analysis of the diagnostic test accuracy of these instruments used to screen for frailty.
Methods:
A diagnostic cross-sectional study was performed. The instrument translation into German followed a standardized process. Prefinal versions were clinically tested on older adults who gave structured in-depth feedback on the scales in order to compile a final revision of the German language scale versions. For the analysis of diagnostic test accuracy (criterion validity), PRISMA-7, FRAIL scale and GFI were considered the index tests. Two reference tests were applied to assess frailty, either based on Fried's model of a Physical Frailty Phenotype or on the model of deficit accumulation, expressed in a Frailty Index.
Results:
Prefinal versions of the German translations of each instrument were produced and completed by 52 older participants (mean age: 73 ± 6 years). Some minor issues concerning comprehensibility and semantics of the scales were identified and resolved. Using the Physical Frailty Phenotype (frailty prevalence: 4%) criteria as a reference standard, the accuracy of the instruments was excellent (area under the curve AUC >0.90). Taking the Frailty Index (frailty prevalence: 23%) as the reference standard, the accuracy was good (AUC between 0.73 and 0.88).
Conclusion:
German language versions of PRISMA-7, FRAIL scale and GFI have been established and preliminary results indicate sufficient diagnostic test accuracy that needs to be further established.
Background:
This report describes the levels of physical function in U.S. Chinese older adults utilizing self-reported and performance-based measures, and examines the association between sociodemographic characteristics and physical function.
Methods:
The Population Study of Chinese Elderly in Chicago enrolled an epidemiological cohort of 3,159 community-dwelling Chinese older adults aged 60 and older. We collected self-reported physical function using Katz activities of daily living and Lawton instrumental activities of daily living items, the Index of Mobility scale, and the Index of Basic Physical Activities scale. Participants were also asked to perform tasks in chair stand, tandem stand, and timed walk. We computed Pearson and Spearman correlation coefficients to examine the correlation between sociodemographic and physical function variables.
Results:
A total of 7.8% of study participants experienced activities of daily living impairment, and 50.2% experienced instrumental activities of daily living impairment. With respect to physical performance testing, 11.4% of the participants were not able to complete chair stand for five times, 8.5% of the participants were unable to do chair stands at all. Older age, female gender, lower education level, being unmarried, living with fewer people in the same household, having fewer children, living fewer years in the United States, living fewer years in the community, and worsening health status were significantly correlated with lower levels of physical function.
Conclusions:
Utilizing self-reported and performance-based measures of physical function in a large population-based study of U.S. Chinese older adults, our findings expand current understanding of minority older adults' functional status.
In this study, we evaluated the Groningen Frailty Indicator (GFI) and the G8 questionnaire as screening tools for a Comprehensive Geriatric Assessment (CGA) in older patients with cancer.
Eligible patients with various types and stages of cancer were evaluated for frailty before treatment. Patients were categorized as patients with a normal CGA and abnormal CGA (≥2 impaired tests). The diagnostic performance of the screening tools was evaluated against the CGA with Receiver Operating Characteristic analysis.
In total, 170 patients (79 women) with median age 77years old (range 66-97years) were included. Sixty-four percent of patients had an abnormal CGA while according to the GFI (GFI≥4) and G8 questionnaire (G8≤14) 47% and 76% of patients had an abnormal screening test, respectively. Overall, there was no significant difference (p=0.97) in diagnostic performance between the two screening tools. The Area Under the Curve was 0.87 for both tools. For the GFI and G8 questionnaire the sensitivity was respectively 66% (95% CI: 56-75%), 92% (95% CI: 85-96%); the negative predictive value (NPV): 59% (95 CI%: 49-69%), 78% (95% CI: 63-88%); and the specificity: 87% (95% CI: 76-94%), 52% (95% CI: 39-65%).
In this study, we showed that overall both the GFI and the G8 questionnaire were able to separate older patients with cancer with a normal and abnormal CGA. For the G8 questionnaire, an adequate sensitivity and NPV were demonstrated, however at the expense of the specificity. For the GFI, we suggest to lower the threshold with one point to GFI ≥3 to screen patients for a CGA.
To operationalize frailty using eight scales and to compare their content validity, feasibility, prevalence estimates of frailty, and ability to predict all-cause mortality.
Secondary analysis of the Survey of Health, Ageing and Retirement in Europe (SHARE).
Eleven European countries.
Individuals aged 50 to 104 (mean age 65.3 ± 10.5, 54.8% female, N = 27,527).
Frailty was operationalized using SHARE data based on the Groningen Frailty Indicator, the Tilburg Frailty Indicator, a 70-item Frailty Index (FI), a 44-item FI based on a Comprehensive Geriatric Assessment (FI-CGA), the Clinical Frailty Scale, frailty phenotype (weighted and unweighted versions), the Edmonton Frail Scale, and the FRAIL scale.
All scales had fewer than 6% of cases with at least one missing item, except the SHARE-frailty phenotype (11.1%) and the SHARE-Tilburg (12.2%). In the SHARE-Groningen, SHARE-Tilburg, SHARE-frailty phenotype, and SHARE-FRAIL scales, death rates were 3 to 5 times as high in excluded cases as in included ones. Frailty prevalence estimates ranged from 6% (SHARE-FRAIL) to 44% (SHARE-Groningen). All scales categorized 2.4% of participants as frail. Of unweighted scales, the SHARE-FI and SHARE-Edmonton scales most accurately predicted mortality at 2 (SHARE-FI area under the receiver operating characteristic curve (AUC) = 0.77, 95% confidence interval (CI) = 0.75-0.79); SHARE-Edmonton AUC = 0.76, 95% CI = 0.74-0.79) and 5 (both AUC = 0.75, 95% CI = 0.74-0.77) years. The continuous score of the weighted SHARE-frailty phenotype (AUC = 0.77, 95% CI = 0.75-0.78) predicted 5-year mortality better than the unweighted SHARE-frailty phenotype (AUC = 0.70, 95% CI = 0.68-0.71), but the categorical score of the weighted SHARE-frailty phenotype did not (AUC = 0.70, 95% CI = 0.68-0.72).
Substantive differences exist between scales in their content validity, feasibility, and ability to predict all-cause mortality. These frailty scales capture related but distinct groups. Weighting items in frailty scales can improve their predictive ability, but the trade-off between specificity, predictive power, and generalizability requires additional evaluation.
The Index of ADL was developed to study results of treatment and prognosis in the elderly and chronically ill. Grades of the Index summarize over-all performance in bathing, dressing, going to toilet, transferring, continence, and feeding. More than 2,000 evaluations of 1,001 individuals demonstrated use of the Index as a survey instrument, as an objective guide to the course of chronic illness, as a tool for studying the aging process, and as an aid in rehabilitation teaching. Of theoretical interest is the observation that the order of recovery of Index functions in disabled patients is remarkably similar to the order of development of primary functions in children. This parallelism, and similarity to the behavior of primitive peoples, suggests that the Index is based on primary biological and psychosocial function, reflecting the adequacy of organized neurological and locomotor response.
Frailty is the most problematic expression of population ageing. It is a state of vulnerability to poor resolution of homoeostasis after a stressor event and is a consequence of cumulative decline in many physiological systems during a lifetime. This cumulative decline depletes homoeostatic reserves until minor stressor events trigger disproportionate changes in health status. In landmark studies, investigators have developed valid models of frailty and these models have allowed epidemiological investigations that show the association between frailty and adverse health outcomes. We need to develop more efficient methods to detect frailty and measure its severity in routine clinical practice, especially methods that are useful for primary care. Such progress would greatly inform the appropriate selection of elderly people for invasive procedures or drug treatments and would be the basis for a shift in the care of frail elderly people towards more appropriate goal-directed care.
To enable prevention of poor outcome in elderly people, a valid instrument is required to detect individuals at high risk. The concept of frailty is a better predictor than age alone. The Groningen Frailty Indicator (GFI) has been developed to identify frailty. We assessed feasibility, reliability, and construct validity of the self-assessment version of the GFI.
Cross-sectional.
Community-based.
Home-dwelling and institutionalized elderly persons were included in the study (n = 353) who met the following inclusion criteria: persons 65 years and older who were able to fill out questionnaires.
The feasibility of the GFI was assessed by determining the proportion of missing values per item. The internal consistency reliability of the GFI was established by calculating the KR-20. Mann-Whitney and Kruskal-Wallis tests were applied to assess discrimination between specific subgroups (known group validity). Convergent and discriminant validity was assessed using Spearman Rank correlations between GFI and diseases and disorders, case complexity, and health care needs (INTERMED), life satisfaction (Cantril Ladder of Life), activities of daily living (Katz), quality of life (EQ-5D), and mental health (SF-36). Finally, we used multivariate regression analyses to evaluate the cutoff score of the GFI (<4 versus ≥4).
A total of 296 (84%) of the participants completed all items of the GFI; the internal consistency was 0.68. The GFI yielded statistically significant GFI scores for subgroups (known group validity). The correlations for the convergent (range 0.45 to 0.61) and discriminant validity (range 0.08 to 0.50) were also as hypothesized. In contrast with nonfrail participants, frail older persons had higher levels of case complexity, disability, and lower quality of life and life satisfaction.
This study supports the feasibility, reliability, and validity of the self-assessment version of the GFI in home-dwelling and institutionalized elderly people.
In order to be able to identify frail community-dwelling older people, a reliable and valid definition of the concept of frailty is necessary. The aim of this study was to provide an overview of the literature on conceptual and operational definitions of frailty, and to determine which definitions are most appropriate for identifying frail community-dwelling older people. Therefore, a computerized search was performed in the PubMed database, Web of Science and PsychInfo. A successful definition of frailty reflects a multidimensional approach, makes clear its dynamic state, predicts adverse outcomes, does not include disease, comorbidity or disability, and meets the criterion of practicability. None of the current conceptual and operational definitions meet these criteria. In this article a new integral conceptual definition of frailty is proposed which meets the criteria of a successful definition.
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.
Evaluation of psychiatric screening and diagnostic tests has benefited from the application of sensitivity, specificity, the kappa-statistic, and predictive values. These measures derive their meaning from a single criterion threshold. Receiver operating characteristic (ROC) analysis extends assessment of test performance by providing information about all possible pairs of achievable sensitivity and specificity values. The ROC analysis offers a comprehensive means for comparing different tests or different scoring procedures for one test. As a demonstration we used the ROC analysis to evaluate three types of scoring rules for one psychiatric test, the Health Opinion Survey. The demonstration indicated that ROC analysis can profitably take a place among the standard methods for test evaluation in psychiatric research. In addition, ROC analysis can assist clinicians in selecting appropriate test procedures for particular patient populations.
To develop and test the effectiveness of a 5-item version of the Geriatric Depression Scale (GDS) in screening for depression in a frail community-dwelling older population.
A cross-sectional study.
A geriatric outpatient clinic at the Sepulveda VA Medical Center, Sepulveda, California.
A total of 74 frail outpatients (98.6% male, mean age 74.6) enrolled in an ongoing trial.
Subjects had a comprehensive geriatric assessment that included a structured clinical evaluation for depression with geropsychiatric consultation. A 5-item version of the GDS was created from the 15-item GDS by selecting the items with the highest Pearson chi2 correlation with clinical diagnosis of depression. Sensitivity, specificity, diagnostic accuracy, and positive and negative predictive values were calculated for the 15-item GDS and the new 5-item scale.
Subjects had a mean GDS score of 6.2 (range 0-15). Clinical evaluation found that 46% of subjects were depressed. The depressed and not depressed groups were similar with regard to demographics, mental status, educational level, and number of chronic medical conditions. Using clinical evaluation as the gold standard for depression, the 5-item GDS (compared with the 15-item GDS results shown in parentheses) had a sensitivity of .97 (.94), specificity of .85 (.83), positive predictive value of .85 (.82), negative predictive value of .97 (.94), and accuracy of .90 (.88) for predicting depression. Significant agreement was found between depression diagnosis and the 5-item GDS (kappa = 0.81). Multiple other short forms were tested, and are discussed. The mean administration times for the 5- and 15-item GDS were .9 and 2.7 minutes, respectively.
The 5-item GDS was as effective as the 15-item GDS for depression screening in this population, with a marked reduction in administration time. If validated elsewhere, it may prove to be a preferred screening test for depression.
With the increase in the number of multinational and multicultural research projects, the need to adapt health status measures for use in other than the source language has also grown rapidly. 1,4,27 Most questionnaires were developed in English-speaking countries, 11 but even within these countries, researchers must consider immigrant populations in studies of health, especially when their exclusion could lead to a systematic bias in studies of health care utilization or quality of life. 9,11 The cross-cultural adaptation of a health status selfadministered questionnaire for use in a new country, culture, and/or language necessitates use of a unique method, to reach equivalence between the original source and target versions of the questionnaire. It is now recognized that if measures are to be used across cultures, the items must not only be translated well linguistically, but also must be adapted culturally to maintain the content validity of the instrument at a conceptual level across different cultures. 6,11‐13,15,24 Attention to this level of detail allows increased confidence that the impact of a disease or its treatment is described in a similar manner in multinational trials or outcome evaluations. The term “cross-cultural adaptation” is used to encompass a process that looks at both language (translation) and cultural adaptation issues in the process of preparing a questionnaire for use in another setting. Cross-cultural adaptations should be considered for several different scenarios. In some cases, this is more obvious than in others. Guillemin et al 11 suggest five different examples of when attention should be paid to this adaptation by comparing the target (where it is going to be used) and source (where it was developed) language and culture. The first scenario is that it is to be used in the same language and culture in which it was developed. No adaptation is necessary. The last scenario is the opposite extreme, the application of a questionnaire in a different culture, language and country—moving the Short Form 36-item questionnaire from the United States (source) to Japan (target) 7 which would necessitate translation and cultural adaptation. The other scenarios are summarized in Table 1 and reflect situations when some translation and/or adaptation is needed. The guidelines described in this document are based on a review of cross-cultural adaptation in the medical, sociological, and psychological literature. This review led to the description of a thorough adaptation process designed to maximize the attainment of semantic, idiomatic, experiential, and conceptual equivalence between the source and target questionnaires. 13 . Further experience in cross-cultural adaptation of generic and diseasespecific instruments and alternative strategies driven by different research groups 18 have led to some refinements
Relationship between cognitive function and fall among elderly adults in home-based setting
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