Article

Predictive Performance of 7 Frailty Instruments for Short-term Disability, Falls and Hospitalization among Chinese Community-dwelling Older Adults: A Prospective Cohort Study

February 2021
International Journal of Nursing Studies 117(1):103875

DOI:10.1016/j.ijnurstu.2021.103875

Authors:

Peking University

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.

The validity of Turkish version of Social Frailty Index in older adults: An index of social attributes predictive of mortality

Article

Oct 2024

Purpose: The aim of this study was to examine the validity of Turkish version of Social Frailty Index in older adults. Material and methods: 102 older adults aged 65 and over were included in the study. Hodkinson Mental Test was first applied to older adults. Older adults who scored 6 points or above were included. To evaluate the validity of "Social Frailty Index", Social Inclusion Scale, Older People's Quality of Life-Brief (OPQOL-Brief) and Lubben Social Network Scale were applied to the participants. To determine the reliability of "Social Frailty Index", the test was re-tested at one-week intervals on older adults who did not receive any treatment. Confirmatory factor analysis AMOS 23.0 was used to determine the conformity of the structure to the original model. For concurrent validity, the correlation analysis applied. Intraclass correlation coefficient (ICC [2,1], absolute agreement, 2-way random effects model) was used to determine the reliability of the scale. Results: The fit of the Turkish version of Social Frailty Index to the model described in the original article was determined to be acceptable-excellent (Demographics (DEM), General Resources and Life History (GRLH), Social Activities (SA) and Fulfillment of Basic Social Needs (FBSN)) (CMIN/DF=1.36, GFI=0.93, IFI=0.90, RMSEA=0.06 and SRMR=0.07). In the correlation analysis conducted to determine its concurrent validity, Social Frailty Index had a moderate correlation with Social Inclusion Scale (r: -0.47; p<0.001) and OPQOL-Brief (r: -0.47; p<0.001). Social Frailty Index had no correlation with Lubben Social Network Scale (r: -0.03; p: 0.81). Test-retest reliability of Social Frailty Index was excellent [ICC(2,1)=0.90, %95 CI 0.84-0.93, p<0.001]. Conclusion: The Turkish version of the Social Frailty Index is valid and can be used to predict mortality risk based on the estimated social risk. The adapted Social Frailty Index is not adequately capturing aspects related to the network and social support. Clinical trials number: NCT06288789.

Use of the Tilburg frailty indicator in longitudinal studies with older adults: A scoping review

Article

Full-text available

Apr 2023
J ADV NURS

Aim To understand how researchers applied the Tilburg Frailty Indicator (TFI) to older adults. The use of the TFI was examined based on the Integral Conceptual Model of Frailty (ICMF). Design A scoping review. Data Sources A database search was conducted without a time limit in PubMed, CINAHL, Embase and the Cochrane library. A hand search was also conducted. Review Methods Research questions were developed based on the population‐concept‐context framework suggested by the Joanna Briggs Institute (2017). Studies were included if topics were related to the use of the TFI or ICMF and designs were longitudinal studies. Results A total of 37 studies met the inclusion criteria. Studies were reviewed according to the tested pathways of the ICMF: determinants of frailty or adverse outcomes, adverse outcomes of frailty and comparison of predictive power between frailty measures. Conclusion The TFI is a useful tool to screen for frailty and predict health outcomes in older adults. Among the pathways of the ICMF, relationships between social factors and frailty were reported in several studies. Despite this relationship, social factors were considered as items to assess the social domain of frailty rather than determinants of frailty. The predictive power of the TFI was not superior to other frailty measures, but it had a high sensitivity. Impact This study demonstrates the usability of the TFI in older adults living in various conditions. Further studies are required to identify more effective ways to screen frailty using the TFI. Patient or Public Contribution No patient or public involvement in this study.

Frailty Transitions in Older Persons With Lung Function Impairment: A Population-Based Study

Article

Full-text available

Oct 2022
J GERONTOL A-BIOL

Background: The ageing population and its burden on health-care systems warrant early detection of patients at risk of functional decline and mortality. We aimed to assess frailty transitions and its accuracy for mortality prediction in subjects with impaired spirometry (Preserved Ratio Impaired Spirometry [PRISm] or Chronic Obstructive Pulmonary Disease [COPD]). Methods: In participants from the population-based Rotterdam Study (mean age 69.1±8.9 years), we examined whether PRISm (Forced Expiratory Volume in 1 second [FEV1]/Forced Vital Capacity [FVC]≥70% and FEV1<80%) or COPD (FEV1/FVC<70%) affected frailty transitions (progression/recovery between frailty states [robust, prefrailty and frailty], lost to follow-up or death) using age-, sex- and smoking state-adjusted multinomial regression models yielding odd's ratios (OR). Second, we assessed diagnostic accuracy of frailty score for predicting mortality in subjects with COPD using c-statistics. Results: Compared to subjects with normal spirometry, subjects with PRISm were more likely to transit from robust (OR 2.2[1.2-4.2], p<0.05) or prefrailty (OR 2.6[1.3-5.5], p<0.01) towards frailty. Subjects with PRISm (OR 0.4[0.2-0.8], p<0.05) and COPD (OR 0.6[0.4-1.0], NS) were less likely to recover from their frail state, and were more likely to progress from any frailty state towards death (OR between 1.1 and 2.8, p<0.01). Accuracy for predicting mortality in subjects with COPD significantly improved when adding frailty score to age, sex and smoking status (90.5[82.3-89.8] vs 77.9[67.2-88.6], p<0.05). Conclusion: Participants with PRISm or COPD more often developed frailty with poor reversibility. Assessing physical frailty improved risk stratification for subjects with impaired spirometry for predicting increased life years.

Comparison of the Clinical-Functional Vulnerability Index and the Frailty Phenotype for the identification of falls in older individuals: a cross-sectional study

Article

May 2022

Background: Frailty increases the risk of falls, disability and death in older adults. The Cardiovascular Health Study identified a frailty phenotype (the Fried Phenotype) that was primarily based on physical domains. Instruments that incorporate additional domains (e.g., cognitive, disability or mood) may more accurately identify falls. Objectives: The study aimed i) to evaluate the association between falls and the number of phenotypes identified by the Fried Phenotype and CFVI-20 scores and ii) to compare the strength of the association between falls and each frailty instrument. Methods: This study used the CFVI-20 and the Fried Phenotype and reported falls during the last twelve months. Logistic regression models, odds ratios (ORs), and ROC curves were used to identify associations and perform comparisons (p<0.05). The reporting of the study followed the Strobe guidelines. Results: This study included 1,826 individuals (mean 70.9 (SD 7.3) years old). Prevalence of pre-frailty and low vulnerability was high (72% and 69%) and comparable between frailty instruments. The number of Fried phenotypes increased the odds of having fallen in the past 12 months (OR: 1.5 to 29.5) and the CFVI-20 scores (11% increase/unit change). The CFVI-20 identified falls more accurately than the Fried Phenotype (AUC: 0.68 vs. 0.60, p < 0.001). Conclusions: The number of phenotypes and the CFVI-20 scores were associated with falls; continuous scores identified falls more accurately than categorical classifications. The CFVI-20 was more strongly associated with falls in community-dwelling older adults than the Fried Phenotype.

Variability and agreement of frailty measures and risk of falls, hospital admissions and mortality in TILDA

Article

Full-text available

Mar 2022

Little is known about the within-person variability of different frailty instruments, their agreement over time, and whether use of repeat assessments could improve the strength of associations with adverse health outcomes. Repeat measurements recorded in 2010–2011 (Wave 1) and 2012 (Wave 2) from The Irish Longitudinal Study on Ageing (TILDA) were used to classify individuals with frailty using the frailty phenotype (FP) and frailty index (FI). Within-person variability and agreement of frailty classifications were assessed using ANOVA and kappa (K) statistics, respectively. Associations of each frailty measure (wave 1, wave 2, or mean of both waves) with risk of falls, hospitalisations and all-cause mortality were assessed using logistic regression. Among 7455 individuals (mean age 64.7 [SD 9.9] years), within-person SD was 0.664 units (95% CI 0.654–0.671) for FP and 2 health deficits (SD 0.050 [0.048–0.051]) for FI. Agreement of frailty was modest for both measures, but higher for FI (K 0.600 [0.584–0.615]) than FP (K 0.370 [0.348–0.401]). The odds ratios (ORs) for all-cause mortality were higher for frailty assessed using the mean of two versus single measurements for FI (ORs for mortality 3.5 [2.6–4.9] vs. 2.7 [1.9–3.4], respectively) and FP (ORs for mortality 6.9 [4.6–10.3] vs. 4.0 [2.8–5.635], respectively). Frailty scores based on single measurements had substantial within-person variability, but the agreement in classification of frailty was higher for FI than FP. Frailty assessed using the mean of two or more measurements recorded at separate visits was more strongly associated with adverse health outcomes than those recorded at a single visit.

Pre-frailty is associated with higher risk of gastroesophageal reflux disease: a large prospective cohort study

Article

Full-text available

Mar 2025

To investigate the prospective association of frailty status, especially the early stage, with the long-term risk of Gastroesophageal reflux disease (GERD) in a large prospective cohort. We included participants who were free of GERD and cancer at baseline and use of aspirin and non-steroidal anti-inflammatory drugs (NSAIDs) from the UK Biobank (UKB). Frailty status was assessed using Fried phenotype including five items (weight loss, exhaustion, low grip strength, low physical activity, slow walking pace) and classified as non-frail, pre-frail, and frail. The outcome was incident GERD. The frailty status was assessed using Cox proportional hazard model. Among 327,965 participants (mean age 56.6 years) at baseline, 151,689 (46.3%) were pre-frail and 14,288 (4.4%) were frail. During a median of 13.5-years of follow-up, 31,027 (9.5%) participants developed GERD. Compared with non-frail participants, pre-frail (hazard ratios [HR] = 1.21, 95% confidence interval [CI] 1.18–1.24) and frail (HR = 1.60, 95% CI 1.52–1.68) participants had significantly higher risks of GERD. Among the five indicators of frailty, exhaustion demonstrated the strongest association with the risk of GERD (HR = 1.42, 95% CI 1.38–1.47). Subgroup analysis showed strong associations among younger (< 60 years), female, high-educated, unemployed participants, and those who had BMI < 18.5 kg/m² (all P for interaction < 0.05). Frailty, especially pre-frail, which is potentially reversible, was associated with higher risk of GERD in middle-aged and older individuals. The findings underscore the importance of integrating routine frailty assessments and interventions, especially at the early stage, to improve digestive health.

Association between physical activity and frailty transitions in middle-aged and older adults: a nationwide longitudinal study

Article

Full-text available

Mar 2025
INT J BEHAV NUTR PHY

Background Frailty has become an important health problem in the middle-aged and older people population. Physical activity (PA) is a key intervention for frailty prevention and management. However, studies of the association between COVID-19 pre-pandemic PA and the worsening or improvement of frailty during the pandemic remain unclear. Methods This longitudinal cohort study used data from the English Longitudinal Study of Ageing (ELSA), including participants aged 50 and over. Three intensities of PA (vigorous, moderate, and mild) were categorized as less than once per week and at least once per week, respectively, based on participant self-report. The frailty index (FI) assessed the frailty status, defining frailty as FI ≥ 25. Logistic regression was applied to examine the association between PA and frailty, estimating odds ratios (OR) and 95% confidence intervals (95% CI). Results Of the 4379 non-frail participants at baseline (median age 67, 54.9% female), 8.1% developed frailty during a mean follow-up of 3.5 years. Among 564 frail participants at baseline (median age 71, 66.5% female), 17.9% regained health. Compared to those engaging in PA less than once per week, participants who engaged in vigorous (OR: 0.47 [95% CI: 0.35–0.62]), moderate (OR: 0.37 [95% CI: 0.29–0.48]), or mild (OR: 0.38 [95% CI: 0.26–0.56]) PA at least once a week had a lower risk of frailty worsening. Additionally, participants who engaged in moderate (OR: 2.04 [95% CI: 1.29–3.21]) or mild (OR: 2.93 [95% CI: 1.54–5.58]) PA at least once a week had a higher likelihood of frailty improvement. Sensitivity analyses based on comprehensive PA levels confirmed these findings. Participants who maintained at least one PA per week had lower frailty worsening (Vigorous, OR: 0.20 [95%CI: 0.12–0.33]; Moderate, OR: 0.13 [95%CI: 0.09–0.19]; Mild, OR: 0.20 [95%CI: 0.11–0.38]) and higher frailty improvement rates (Moderate, OR: 3.43 [95%CI: 1.93–6.11]; Mild, OR: 4.65 [95%CI: 1.90-11.42]). In addition, individuals (Vigorous, OR: 0.35 [95%CI: 0.20–0.60]; Moderate, OR: 0.36 [95%CI: 0.22–0.56]) who transitioned from inactive to active also exhibited a lower risk of frailty. Conclusions This study emphasized the critical role of PA in preventing and improving frailty in middle-aged and older people, especially during the COVID-19 pandemic. Our study also highlighted the importance of maintaining PA habits to reduce frailty risk and promote its improvement. Also, the study indicated that individuals who transitioned from inactive to active had a lower risk of frailty. These findings enriched the understanding of the association between PA and frailty and provided valuable insights for addressing the health impact of future pandemics on middle-aged and older people.

The relationship between frailty and major adverse cardiovascular and cerebrovascular events in Chinese older adults: the mediating effect of lipid accumulation products

Article

Full-text available

Feb 2025

Background Previous studies have proven the relationship between frailty and major adverse cardiovascular and cerebrovascular events (MACCE). However, the potential mechanisms need to be further explored. This study aimed to investigate the mediating effect of lipid accumulation products (LAP) in the relationship between frailty and MACCE. Methods This study recruited 7901 participants aged 45 and above from wave 2011 and 2018 of the China Longitudinal Study of Health and Retirement (CHARLS). Logistic regression models were employed to examine the relationship between frailty and MACCE and the mediating effects of LAP, using the bootstrap method to confirm path effects. Results Frailty group presented the highest risk of MACCE (OR 1.07, 95% CI 1.03–1.10). Frailty directly impacted MACCE (β = 0.045, P = 0.007). Frailty had a significant effect on LAP (β = 12.21, P < 0.01), while LAP had a significant impact on MACCE (β = 11.14, p = 0.014). The mediation effect of LAP accounted for 1.7% of the total effect regarding the frailty with MACCE. Conclusion LAP mediate the relationship between frailty and MACCE. Our findings suggest that instructing frailty patients to have a reasonable diet and exercise to control LAP at a low level may be an effective measure to reduce MACCE. Supplementary Information The online version contains supplementary material available at 10.1186/s13690-025-01520-8.

Analysis of the relationship between abdominal aortic calcification and frailty in the middle-aged and older US population

Article

Full-text available

Feb 2025

Background and Objective: Abdominal aortic calcification (AAC) is a marker of cardiovascular disease and is associated with increased mortality in middle-aged and older populations. However, its relationship with frailty remains unclear. Methods: Data were obtained from the 2013–2014 National Health and Nutrition Examination Survey. AAC was quantified using the Kauppila scoring system based on dual-energy X-ray absorptiometry. Frailty was assessed using the frailty index. Multivariable logistic regression models examined the association between AAC and frailty. Results: A total of 2987 adults aged ≥40 years were included. Compared to individuals with an AAC-8 score of 0, low-risk (AAC-8 score = 1–2; OR: 1.24; 95 % CI, 1.00–1.53) and high-risk AAC (AAC-8 score ≥ 3; OR: 1.83; 95 % CI, 1.03–3.23) were associated with higher odds of frailty. Similarly, mild to moderate AAC (0 < AAC-24 score ≤ 6; OR: 1.26; 95 % CI, 1.03–1.54) and severe AAC (AAC-24 score > 6; OR: 1.79; 95 % CI, 1.07–2.99) showed positive associations with frailty. Conclusions: Among middle-aged and older populations in the United States, there exists a positive correlation between AAC and frailty. Our findings suggest that the AAC score holds promise as a valuable tool for the early identification of frailty.

Association of frailty index with incidence of chronic kidney disease: China Health and Retirement Longitudinal Study

Article

Full-text available

Jan 2025

Frailty is an important risk factor for a wide range of chronic diseases and for mortality risk. This study aims to explore the relationship between frailty and incidence of chronic kidney disease (CKD), particularly on the change and accumulation of frailty. Frailty status was assessed using the frailty index (FI, constructed by 31 items) and categorized as robust, pre-frail, and frail. The accumulation and change in frailty were assessed on the basis of frailty status at baseline and a second survey 4 years after baseline. Logistic regression was used to estimate the association between frailty and developing CKD. A total of 3597 participants (mean age: 59.08 ± 8.94 years old, male: 49.9%) from CHARLS were included. Participants with pre-frailty or frailty status had a higher risk of developing CKD compared with robust participants (pre-frail vs robust, OR 1.78, 95% CI 1.37–2.32, p < 0.001; frail vs robust, OR 2.52, 95% CI 1.67–3.79, p < 0.001). Participants who had a robust status in the two surveys had a significantly lower risk of developing CKD (OR 0.51, 95% CI 0.36–0.75, p < 0.001) compared with those who never had a robust status. Frailty status is significantly associated with the incidence of CKD. The risk of CKD was lower in those who ever had a robust status than in participants who never had a robust status.

The relationship between frailty and major adverse cardiovascular and cerebrovascular events in Chinese older adults: the mediating effect of lipid accumulation products

Preprint

Full-text available

Oct 2024

Influencing Factors and a Predictive Nomogram of Frailty in Chinese Patients with Cancer: A Single-Center Retrospective Study

Article

Full-text available

Sep 2024
EUR J CANCER CARE

Objective. The number of cancer survivors is increasing, and the high prevalence of frailty not only reduces quality of life but also affects the treatment of cancer patients. This study aimed to identify the prevalence and risk factors of frailty in cancer patients and to construct a nomogram to predict the probability of frailty. Methods. Nine hundred fifty-eight cancer patients were included in this retrospective study, randomly divided into a development set (n = 680) and a validation set (n = 278). Frailty was assessed using the Tilburg frailty indicator (TFI). Social support, medical coping styles, and psychological distress were assessed by the Social Support Self-Rating Scale (SSRS), Medical Coping Modes Questionnaire (MCMQ), and distress thermometer (DT), respectively. Results. The prevalence of frailty in cancer patients was 45.93%. Cancer patients who exercised regularly, ate a balanced diet, and actively coped with diseases were less likely to become frail. The risk factors for frailty identified by a multivariate analysis were parenteral nutrition, advanced TNM staging, vegetarian diet, unemployment, psychological distress ≥4, low physical activity, and negative coping styles. These risk factors were used to construct a nomogram, and the C-index, calibration curve, and decision curve analysis (DCA) were used to assess the performance of the nomogram. The C-index was 0.762, and the calibration curve showed satisfactory coherence. The net benefit of the nomogram was better between threshold probabilities of 17%–96% in DCA. Conclusion. Special focus needs to be placed on frail cancer patients due to their high prevalence and severe outcomes. Clinical medical workers could use this nomogram to identify high-risk patients and intervene early to prevent frailty.

Internet use and frailty in middle-aged and older adults: findings from developed and developing countries

Article

Full-text available

Jul 2024

Liang Li

Background With increasing trend of internet use in all age groups, whether internet use can prevent frailty in middle-aged and older adults remains unclear. Methods Five cohorts, including Health and Retirement Study (HRS), China Health and Retirement Longitudinal Study (CHARLS), the Survey of Health, Ageing and Retirement in Europe (SHARE), English Longitudinal Study of Aging (ELSA), and Mexican Health and Aging Study (MHAS), were used in this study. Internet use, social isolation, and frailty status was assessed using similar questions. The Generalized estimating equations models, random effects meta-analysis, COX regression, and mediation analysis were utilized. Results In the multicohort study, a total of 155,695 participants were included in main analysis. The proportion of internet use was varied across countries, ranging from 5.56% in China (CHARLS) to 83.46% in Denmark (SHARE). According to the generalized estimating equations models and meta-analysis, internet use was inversely associated with frailty, with the pooled ORs (95%CIs) of 0.72 (0.67,0.79). The COX regression also showed that participants with internet use had a lower risk of frailty incidence. Additionally, the association was partially mediated by social isolation and slightly pronounced in participants aged 65 and over, male, not working for payment, not married or partnered, not smoking, drinking, and not co-residence with children. Conclusions Our findings highlight the important role of internet use in preventing frailty and recommend more engagements in social communication and activities to avoid social isolation among middle-aged and older adults.

A Case Study of Doormat Craft Business Management by Disabled People's Organizations

Article

Full-text available

Nov 2023

The Pusat Pemberdayaan Mitra Sejahtera (PPDMS) is a Disabled People's Organization (DPO) in Indonesia that continued operating its doormat craft business during the COVID-19 pandemic. This was a unique time, given many constraints on workers in Indonesia. This study aimed to explore the challenges PPDMS faced while running their doormat craft business during the COVID-19 pandemic and what strategies they used to overcome these challenges. A case study was used to explore the unique characteristics of DPO entities and their strategies to continue a sustainable business during the pandemic. Research participants included organizational leaders, members, coordinators, partner subsidiaries, and families of persons with disabilities. Data collection techniques included interviews, observation, and document review. The research findings revealed determinants of the DPO's survival in the doormat craft business, namely (a) transformative leadership based on cooperation, (b) productivity of DPO members and their families, and (c) assistive technology for accessible doormat craft. These findings can inform good practices that can be disseminated to other DPOs.

Social frailty as a predictor of adverse outcomes among older adults: a systematic review and meta-analysis

Article

Full-text available

May 2023
AGING CLIN EXP RES

Background With the aging of the population, frailty has attracted much attention, and the social dimension of frailty, namely social frailty, has also attracted attention. Studies have shown that social frailty can bring some adverse effects to the elderly, such as physical and cognitive function. Aims To explore the risk of adverse health outcomes in older adults with social frailty compared with older adults with non-social frailty. Methods Five databases were systematically searched from inception to February 28, 2023. Screening, data extraction and quality assessment were conducted independently by two researchers. The included studies were longitudinal studies of adverse outcomes in community-dwelling socially frail older adults, and the quality of each study was assessed using the Newcastle‒Ottawa Scale. Results A total of 15 studies were included based on the inclusion criteria, of which 4 were subjected to meta-analysis. The mean age of the included population ranged from 66.3 to 86.5 years. According to existing research, social frailty was predictive of some adverse outcomes, such as incident disability, depressive symptoms, and reduced neuropsychological function. The meta-analysis showed that social frailty had a significant predictive effect on mortality among older adults [HR = 2.27, (95% CI = 1.03–5.00)]. Conclusion In community-dwelling older adults, social frailty was a predictor of mortality, incident disability, depressive symptoms and other adverse outcomes. Social frailty had a negative impact on older adults, so it was necessary to strengthen the screening of social frailty to reduce the incidence of adverse outcomes.

Associations of metabolic heterogeneity of obesity with frailty progression: Results from two prospective cohorts

Article

Full-text available

Dec 2022

Background Previous studies indicated that obesity would accelerate frailty progression. However, obesity is heterogeneous by different metabolic status. The associations of metabolic heterogeneity of obesity with frailty progression remain unclear. Methods A total of 6730 participants from the China Health and Retirement Longitudinal Study (CHARLS) and 4713 from the English Longitudinal Study of Ageing (ELSA) were included at baseline. Metabolic heterogeneity of obesity was evaluated based on four obesity and metabolic phenotypes as metabolically healthy normal weight (MHNW), metabolically unhealthy normal weight (MUNW), metabolically healthy overweight/obesity (MHOO), and metabolically unhealthy overweight/obesity (MUOO). Frailty status was assessed by the frailty index (FI) ranging from 0 to 100 and frailty was defined as FI ≥ 25. Linear mixed‐effect models were used to analyse the associations of metabolic heterogeneity of obesity with frailty progression. Results In the CHARLS, MUOO and MUNW presented the accelerated FI progression with additional annual increases of 0.284 (95% CI: 0.155 to 0.413, P < 0.001) and 0.169 (95% CI: 0.035 to 0.303, P = 0.013) as compared with MHNW. MHOO presented no accelerated FI progression (β: ‐0.011, 95% CI: −0.196 to 0.173, P = 0.904) as compared with MHNW. In the ELSA, the accelerated FI progression was marginally significant for MUOO (β: 0.103, 95% CI: −0.005 to 0.210, P = 0.061) and MUNW (β: 0.157, 95% CI: −0.011 to 0.324, P = 0.066), but not for MHOO (β: ‐0.047, 95% CI: −0.157 to 0.062, P = 0.396) in comparison with MHNW. The associations of MUOO and MUNW with the accelerated FI progression were stronger after excluding the baseline frail participants in both cohorts. The metabolic status changed over time. When compared with stable MHNW, participants who changed from MHNW to MUNW presented the accelerated FI progression with additional annual increases of 0.356 (95% CI: 0.113 to 0.599, P = 0.004) and 0.255 (95% CI: 0.033 to 0.477, P = 0.024) in the CHARLS and ELSA, respectively. The accelerated FI progression was also found in MHOO participants who transitioned to MUOO (CHARLS, β: 0.358, 95% CI: 0.053 to 0.663, P = 0.022; ELSA, β: 0.210, 95% CI: 0.049 to 0.370, P = 0.011). Conclusions Metabolically unhealthy overweight/obesity and normal weight, but not metabolically healthy overweight/obesity, accelerated frailty progression as compared with metabolically healthy normal weight. Regardless of obesity status, transitions from healthy metabolic status to unhealthy metabolic status accelerated frailty progression as compared with stable metabolically healthy normal weight. Our findings highlight the important role of metabolic status in frailty progression and recommend the stratified management of obesity based on metabolic status.

Frailty knowledge level and its influencing factors among older adults in China

Preprint

Full-text available

Oct 2022

Background Raising older adults’ frailty knowledge level and encouraging them to actively engage in the prevention and treatment of frailty is important to promote healthy aging. This study aimed to investigate frailty knowledge level and its influencing factors among community-dwelling older adults in China. Methods This cross-sectional study included a total of 734 community-dwelling older adults in China. A self-designed questionnaire was used to assess their frailty knowledge level. Logistic regression and decision tree analysis were used to examine the association between the following factors and frailty knowledge level: gender, age, residential area, co-residence, marital status, education level, monthly income, pension insurance, smoking status, drinking status, exercise status, body mass index, type of chronic disease, number of oral medications, nutritional status, cognitive status, depression, social activity, social isolation, and frailty. Results Most of the participants (mean age 72.01, standard deviation 9.45) were female (51.1%) and living with a spouse (76.4%). They knew little about frailty and had misunderstandings about frailty. Nearly half of them made a wrong judgment on their frailty status (42.50%). Most participants expected to obtain frailty knowledge in the community (33.92%). Those who were female, lived in rural areas, lived alone, had not attended school, had a monthly income < 3,000RMB, were at risk for malnutrition, were depressed, and were socially isolated were more likely to lack knowledge on frailty. In contrast, those with advanced age and were at pre-frailty or frailty stage were significantly more knowledgeable about frailty. The group that was least knowledgeable about frailty was those who had never attended school or primary school and had loose friend ties (1.3%). Conclusion Frailty knowledge level among older adults in China is low, especially among those at high risk for frailty. Therefore, it is crucial to develop tailored measures to raise frailty knowledge level among older adults in China.

Frailty as a Predictor of Adverse Outcomes among Spanish Community-Dwelling Older Adults

Article

Full-text available

Oct 2022
Int J Environ Res Publ Health

Spain is one of the European countries with the oldest populations. The prevalence of frailty among Spanish older people ranges from 8.4 to 29.4% and currently, is one of the most relevant public health challenges. The Tilburg Frailty indicator (TFI) has been widely used in the community and in healthcare settings for assessing frailty. The objective of this study is to evaluate the predictive performance of the TFI for several adverse outcomes among Spanish community-dwelling older adults. The predictive performance was tested through linear regression analyses and receiver operating characteristics (ROC) curves. A total of 552 Spanish older adults composed the study sample. Participants were assessed at baseline and after 6 months. Main results showed that frailty was strongly and significantly correlated with disability, physical health, mental health and falls efficacy. The TFI score predicted most of these adverse outcomes. The ROC analyses confirmed the acceptable predictive performance of the total frailty. This study provides new evidence confirming that the TFI is a valid tool to predict several adverse outcomes in Spanish older adults, which may allow professionals to plan and activate health and social care resources to support frail patients’ needs.

In response to the Letter to the Editor by Dr AA. Zulﬁqar re our publication "Multidimensional Short Tools to Assess Frailty: a Narrative Review" (Ann Ig. 2022 Mar 18. doi: 10.7416/ai.2022.2516. Online ahead of print)

Article

Jun 2022

We appreciate that Dr. Zulfiqar showed us that they had already demonstrated the validity and reliability of his ZFS scale. Still, it is evident that, in our paper, we could not take it for granted because all the articles they quote have been published after we handed out ours to the Managing Editor of Ann Ig.

Multidimensional Short Tools to assess frailty: a narrative review

Article

Full-text available

Mar 2022

Background: The population of the European Union is progressively ageing, therefore frailty is becoming a crucial public health issue. In recent years there is a growing interest in a multidimensional concept of frailty, that is not only physical but also psychological and social, in line with a person-centered care. Study design: To measure frailty represents a fundamental step to evaluate the needs for care at both population and individual levels. Of course, to assess frailty in a large population is essential to find short and quick tools able to give reliable results in terms of risk of occurrence of negative events, to stratify older adults according to their frailty level. In this way the most appropriate strategies can be chosen and applied, to delay the functional decline associated to frailty and its consequences, such as hospitalization, institutionalization, low quality of life, and death. Methods: In this review we searched on PubMed for articles about scales assessing frailty with peculiar characteristics: published for the first time in 2010, available in English, with a short length and duration of administration, composed by multidimensional domains. Results: Seven scales were found and analyzed: The Zulfiqar Frailty Scale (ZFS), The Pictorial Fit-Frail Scale (PFFS), The Tilburg Frailty Indicator (TFI), The SUNFRAIL Tool, The (fr)AGILE, The Risk Instrument for Screening in the Community (RISC) and The Short Functional Geriatric Evaluation (SFGE). We compared their main features as the number of questions, the time for administration, the domains used and the psychometric properties as validity and reliability, with the aim of providing a set of useful information to health professionals in their everyday work. Conclusions: The use of these tools provides important information to help plan community health and social care and meet individuals' needs for care, but this approach is not common for community care in the EU yet.

T Scores, FRAX, Frailty Phenotype, Falls, and Its Relationship to Fractures in Patients on Maintenance Hemodialysis

Article

Full-text available

Aug 2021

Background: Despite the magnitude of fracture and the consequences in patients receiving hemodialysis, optimal risk assessment tools in this population are not well explored. Frailty and falls-known risk factors for fracture in chronic kidney disease (CKD) and non-CKD populations-are common in patients receiving hemodialysis (HD) therapy. While the relationship between T scores in relation to fractures in patients receiving HD is recognized, there is a paucity of data to the additional contributions of fracture assessment tool (FRAX), frailty status, and falls in its relationship with fracture. Objectives: To evaluate the clinical utility of adding FRAX, frailty status, and falls to T scores at the femoral neck to determine whether it enhances fracture discrimination in patients on maintenance HD. Design: A cross-sectional observational study. Setting: Two main dialysis units in Regina, Saskatchewan, Canada. Patients: A total of 109 patients on maintenance HD at two dialysis units from January 1, 2017, to December 31, 2018, were included in the study. Measurements: Fracture (the main outcome) was documented based on the review of medical charts, self-recall, and additionally vertebral fractures were identified by an x-ray. Areal bone mineral density (BMD) was measured by dual-energy x-ray absorptiometry (DXA). FRAX score was calculated using an online algorithm based on 11 clinical risk factors. We calculated the FRAX score for hip fracture and major osteoprotoic fracture with and without the inclusion of BMD. Frailty was assessed using the Fried criteria, which included assessments of unintentional weight loss, weakness (handgrip strength), slowness (walking speed), and questionnaires for physical activity and self-perceived exhaustion. Patients were enquired about the history and frequency of falls. Methods: A total of 131 patients underwent frailty assessments at the two dialysis units during the dialysis treatment. Following frailty assessments, they were referred for DXA scans and upon receipt of the results undertook FRAX questionnaires. They were additionally sent for lumbar x-rays and contacted for a history of falls. Association between the BMD-T score, FRAX, frailty status, falls, with fracture were examined with sequential multivariable logistic regression models. Differences were considered statistically significant at P values <.05. Results: A total of 109 patients were included in the data analysis. The composite of fracture occurred in 37.6% of patients. About 59.3% were identified as frail, and 29% of the participants had at least one fall in the last year. On multivariate regression analysis, each lower standard deviation (SD) in femoral neck T score was associated with 48% higher odds of fracture (odds ratio [OR] = 1.48; 95% confidence interval [CI] 1.20-1.68, P = .005). With the inclusion for FRAX scores (hip), the OR for fracture remained significant at 1.38 (OR = 1.38, 95% CI 1.04-1.63, P = .043). The addition of frailty status and history of falls did not further improve the model. Low T score and FRAX were both independent risk factors in patients on HD therapy. Limitations: This is a single-center study with a small sample size which limits the generalizability of the findings. Due to the cross-sectional study, associations identified may be difficult to interpret. Conclusions: Both BMD measurements by DXA and FRAX are useful tools to assess fracture in patients receiving HD. The addition of frailty status and history of falls is not associated with fractures in this population. Larger prospective studies are needed to determine whether the inclusion of frailty and falls to the conventional models will improve fracture assessment in the population receiving HD. Trial registration: The study was not registered on a publicly accessible registry as it did not involve health care intervention on human participants.

An early predictive model of frailty for older inpatients according to nutritional risk: protocol for a cohort study in China

Article

Full-text available

Aug 2021
BMC Geriatr

Background Previous reports suggest that the attributes of frailty are multidimensional and include nutrition, cognition, mentality, and other aspects. We aim to develop an early warning model of frailty based on nutritional risk screening and apply the frailty early warning model in the clinic to screen high-risk patients and provide corresponding intervention target information. Methods The proposed study includes two stages. In the first stage, we aim to develop a prediction model of frailty among older inpatients with nutritional risk. Study data were collected from a population-based aging cohort study in China. A prospective cohort study design will be used in the second stage of the study. We will recruit 266 older inpatients (age 65 years or older) with nutritional risk, and we will apply the frailty model in the clinic to explore the predictive ability of the model in participants, assess patients’ health outcomes with implementation of the frailty model, and compare the model with existing frailty assessment tools. Patients’ health outcomes will be measured at admission and at 30-day follow-up. Discussion This project is the first to develop an early prediction model of frailty for older inpatients according to nutritional risk in a nationally representative sample of Chinese older inpatients of tertiary hospitals. The results will hopefully help to promote the development of more detailed frailty assessment tools according to nutritional risk, which may ultimately lead to reduced health care costs and improvement in independence and quality of life among geriatric patients. Trial registration Chinese Clinical Trial Registry, ChiCTR1800017682 , registered August 9, 2018; and ChiCTR2100044148 , registered March 11, 2021.

Joint association of frailty index and biological age with chronic obstructive pulmonary disease: a cohort study from CHARLS

Article

Full-text available

May 2025

Frailty and Incident Diabetes among Middle-Aged and Older Adults: Evidence from a Large Prospective Cohort in China

Article

May 2025
NUTR METAB CARDIOVAS

Bidirectional relationship between diabetes and frailty in middle-aged and older adults: A systematic review and meta-analysis

Article

Apr 2025
ARCH GERONTOL GERIAT

Association of frailty index with new-onset diabetes: from the China Health and Retirement Longitudinal Study (CHARLS)

Article

Jan 2025
ACTA DIABETOL

To investigate the association of frailty status and its changes with new-onset diabetes. A total of 4638 participants from the China Health and Retirement Longitudinal Study (CHARLS) were included. Frailty status was assessed by the frailty index (FI) and categorized as robust, pre-frail, and frail. Changes in frailty were assessed based on frailty status at wave1 and wave3 of CHARLS. New-onset diabetes was identified by self-reported physician-diagnosed or diagnosed by glucose or glycosylated haemoglobin during follow-up period. Logistic regression was used to examine the association of frailty and outcomes. 51.6%, 38.1% and 10.3% of the individuals were respectively classified as robust, pre-frail, and frail at baseline. The risk of new-onset diabetes was significantly higher in the pre-frailty [odds ratio (OR) (95% confidence interval (CI)): 1.326 (1.101–1.597), p = 0.003)] and frailty [OR(95% CI): 1.721 (1.304–2.271), p < 0.001)] than the robust. A total of 3145 participants were included in the changes of frailty status analyses. Compared with the stable robust individuals, individuals who developed from robust to frailty status [OR (95%CI): 3.752 (1.647–8.547), p = 0.002] had an elevated risk of new-onset diabetes. In addition, participants who ever had a robust status in the two surveys had a significantly lower risk of new-onset diabetes compared to those who never had a robust status [OR (95%CI) 0.666 (0.483–0.920), p = 0.014)]. Frailty status is significantly associated with the risk of new-onset diabetes. The progression from robust to frailty or pre-frailty increased the risk of new-onset diabetes.

Exploring the mechanism of change in exercise behavior during a theory-based exercise intervention among community-dwelling (pre)frail older adults: A stepped wedge cluster randomized trial

Article

Dec 2024

Effectiveness of a theory-underpinning exercise intervention among community-dwelling (pre)frail older adults: A stepped-wedge cluster-randomized trial

Article

Oct 2024
INT J NURS STUD

Development and Validation of Prediction Models for Incident Reversible Cognitive Frailty Based on Social-Ecological Predictors Using Generalized Linear Mixed Model and Machine Learning Algorithms: A Prospective Cohort Study

Article

Aug 2024

This study aimed to develop and validate prediction models for incident reversible cognitive frailty (RCF) based on social-ecological predictors. Older adults aged ≥60 years from China Health and Retirement Longitudinal Study (CHARLS) 2011–2013 survey were included as training set ( n = 1230). The generalized linear mixed model (GLMM), eXtreme Gradient Boosting, support vector machine, random forest, and Binary Mixed Model forest were used to develop prediction models. All models were evaluated internally with 5-fold cross-validation and evaluated externally via CHARLS 2013–2015 survey ( n = 1631). Only GLMM showed good discrimination (AUC = 0.765, 95% CI = 0.736, 0.795) in training set, and all models showed fair discrimination (AUC = 0.578–0.667, 95% CI = 0.545, 0.725) in internal and external validation. All models showed acceptable calibration, overall prediction performance, and clinical usefulness in training and validation sets. Older adults were divided into three groups using risk score based on GLMM, which could assist healthcare providers to predict incident RCF, facilitating early identification of high-risk population.

Unveiling the multi-dimensional frailty network among older cancer survivors in China: A network analysis study

Article

Jul 2024

Psychometric Properties of the FRAIL Scale for Frailty Screening: A Scoping Review

Article

Jul 2024
J AM MED DIR ASSOC

Abstract Objectives The aim of this study was to identify and map the available psychometric evidence of the FRAIL scale to screen frailty among older adults. Design Scoping review of published articles on 9 databases (PubMed, Scopus, Web of Science, CINAHL, Cochrane, Embase, PsycINFO, VHL Regional Portal, and Epistemonikos) and 8 gray literature sources. Setting and Participants Studies in adults or older adults, in both inpatient and outpatient settings (without context restrictions). Methods Cross-cultural adaptations, validity and reliability evidence studies, whose main objective was to develop and/or validate and/or culturally adapt the FRAIL Scale to assess frailty in adults or older adults, published since 2007 were included in this scoping review. The databases were searched between February and March 2023.The JBI methodology for scoping reviews was used to guide the process. The protocol of this study was registered on the Open Science Framework platform. Results Of the 1031 records found during the search, 40 articles that met the established criteria for analysis were included. Nearly 1 in 10 countries worldwide (11.9%) have psychometric evidence regarding this scale. Ten studies were identified with the goal of cross-cultural adaptation and/or validation in a different cultural context for the first time. Twenty-one of 40 studies used Morley 2012 operationalization of FRAIL Scale criteria. Thirty-nine studies provided evidence of associations with other variables. The rest of the evidence for content, internal structure, response processes, and reliability was only evaluated in cross-cultural adaptation studies, with limitations. Conclusions and Implications In conclusion, there is some evidence of validity for FRAIL Scale; nevertheless, studies are needed to adapt the scale to new cultures, using rigorous Cross-Cultural Adaptation processes, and to provide new evidence of validity and reliability, to strengthen and consolidate the body of knowledge for its application to various patient groups and context. Keywords Frailty frail older adult psychometrics geriatric assessment cross-cultural comparison validation study

Internet use and frailty in middle-aged and older adults: Findings from developed and developing countries

Preprint

Full-text available

Mar 2024

Liang Li

Background With increasing trend of internet use in all age groups, whether internet use can prevent frailty in middle-aged and older adults remains unclear. Methods Five cohorts across the United States, England, 28 Europe countries, China and Mexico were used in this study. Frailty status was assessed by frailty index based on a standard procedure. Generalized estimating equations models, random effects meta-analysis, and mediation analysis were utilized. Results In the multicohort study, a total of 155,695 participants were included. The proportion of internet use was varied across countries, ranging from 5.56% in China to 83.46% in Denmark. According to the generalized estimating equations models and meta-analysis, internet use was inversely associated with frailty, with the pooled ORs (95%CIs) of 0.72 (0.67,0.79). Additionally, the association was partially mediated by social activities and slightly pronounced in participants aged 65 and over, male, not working for payment, not married or partnered, not smoking, drinking, and not co-residence with children. Conclusions Our findings highlight the important role of internet use in the incidence of frailty and recommend more engagements in social activities among middle-aged and older adults. Grasping the opportunity to spread health information and increase social activities by the internet would decrease the incidence of frailty.

The impact of frailty on short-term prognosis among discharged adult stroke patients: A multicenter prospective cohort study

Article

Mar 2024
INT J NURS STUD

Changes in frailty and incident cardiovascular disease in three prospective cohorts

Article

Jan 2024
EUR HEART J

Background and Aims Previous studies found that frailty was an important risk factor for cardiovascular disease (CVD). However, previous studies only focused on baseline frailty status, not taking into consideration the changes in frailty status during follow-up. The aim of this study was to investigate the associations of changes in frailty status with incident CVD. Methods This study used data of three prospective cohorts: China Health and Retirement Longitudinal Study (CHARLS), English Longitudinal Study of Ageing (ELSA), and Health and Retirement Study (HRS). Frailty status was evaluated by the Rockwood frailty index and classified as robust, pre-frail, or frail. Changes in frailty status were assessed by frailty status at baseline and the second survey which was two years after the baseline. Cardiovascular disease was ascertained by self-reported physician-diagnosed heart disease (including angina, heart attack, congestive heart failure, and other heart problems) or stroke. Cox proportional hazard models were used to calculate the hazard ratio (HR) and 95% confidence interval (95% CI) after adjusting for potential confounders. Results A total of 7116 participants from CHARLS (female: 48.6%, mean age: 57.4 years), 5303 from ELSA (female: 57.7%, mean age: 63.7 years), and 7266 from HRS (female: 64.9%, mean age: 65.1 years) were included according to inclusion and exclusion criteria. The median follow-up periods were 5.0 years in the CHARLS, 10.7 years in the ELSA, and 9.5 years in the HRS. Compared with stable robust participants, robust participants who progressed to pre-frail or frail status had increased risks of incident CVD (CHARLS, HR = 1.84, 95% CI: 1.54–2.21; ELSA, HR = 1.53, 95% CI: 1.25–1.86; HRS, HR = 1.59, 95% CI: 1.31–1.92). In contrast, frail participants who recovered to robust or pre-frail status presented decreased risks of incident CVD (CHARLS, HR = 0.62, 95% CI: 0.47–0.81; ELSA, HR = 0.49, 95% CI: 0.34–0.69; HRS, HR = 0.70, 95% CI: 0.55–0.89) when compared with stable frail participants. These decreased risks of incident CVD were also observed in pre-frail participants who recovered to robust status (CHARLS, HR = 0.66, 95% CI: 0.52–0.83; ELSA, HR = 0.65, 95% CI: 0.49–0.85; HRS, HR = 0.71, 95% CI: 0.56–0.91) when compared with stable pre-frail participants. Conclusions Different changes in frailty status are associated with different risks of incident CVD. Progression of frailty status increases incident CVD risks, while recovery of frailty status decreases incident CVD risks.

Preserved ratio impaired spirometry and chronic obstructive pulmonary disease accelerate frailty progression: evidence from a prospective cohort study

Article

Jul 2023
CHEST

Background: Chronic obstructive pulmonary disease (COPD) was found to associate with frailty. However, there is inadequate longitudinal evidence for associations of COPD with frailty progression. Furthermore, recent studies revealed a new phenotype of lung function impairment: preserved ratio impaired spirometry (PRISm). Associations of PRISm and its transitions with frailty progression are unclear. Research question: What are the associations of PRISm, transitions of PRISm, and COPD with frailty progression? Study design and methods: To analyze the associations of PRISm and COPD with frailty progression, 5,901 subjects were included from the English Longitudinal Study of Ageing. Subjects were classified into three lung function patterns of normal spirometry, PRISm, and COPD. Frailty progression was assessed by repeated measurements of the frailty index (FI) during follow-up. Among these 5,901 subjects, 3,765 subjects were included to analyze the associations of PRISm transitions with frailty progression. PRISm transitions were assessed based on the changes of lung function patterns after a four-year interval. Linear mixed-effect models were used for statistical analyses. Results: The median follow-up periods were 9.5 years for the analyses of PRISm and COPD with frailty progression and 5.8 years for PRISm transitions with frailty progression. When compared with normal spirometry, subjects with PRISm and COPD presented accelerated FI progression with additional annual increases of 0.301(95%CI: 0.211 to 0.392, P<0.001) and 0.172(95%CI: 0.102 to 0.242, P<0.001), respectively. Subjects who transitioned from normal spirometry to PRISm also presented accelerated FI progression when compared with stable normal spirometry (β=0.242, 95%CI: 0.008 to 0.476, P=0.042). However, no accelerated FI progression was found in PRISm subjects who transitioned to normal spirometry (β=0.119, 95%CI: -0.181 to 0.418, P=0.438). Interpretation: Our findings indicate that PRISm and COPD are associated with accelerated frailty progression. Further studies are needed to elucidate the causality of PRISm and COPD with frailty.

Development and validation of a preliminary clinical support system for measuring the probability of incident 2-year (pre)frailty among community-dwelling older adults: A prospective cohort study

Article

Jun 2023
INT J MED INFORM

Objective: To develop the wed-based system for predicting risk of (pre)frailty among community-dwelling older adults. Materials and methods: (Pre)frailty was determined by physical frailty phenotype scale. A total of 2802 robust older adults aged ≥60 years from the China Health and Retirement Longitudinal Study (CHARLS) 2013-2015 survey were randomly assigned to derivation or internal validation cohort at a ratio of 8:2. Logistic regression, Random Forest, Support Vector Machine and eXtreme Gradient Boosting (XGBoost) were used to construct (pre)frailty prediction models. The Grid search and 5-fold cross validation were combined to find the optimal parameters. All models were evaluated externally using the temporal validation method via the CHARLS 2011-2013 survey. The (pre)frailty predictive system was web-based and built upon representational state transfer application program interfaces. Results: The incidence of (pre)frailty was 34.2 % in derivation cohort, 34.8 % in internal validation cohort, and 32.4 % in external validation cohort. The XGBoost model achieved better prediction performance in derivation and internal validation cohorts, and all models had similar performance in external validation cohort. For internal validation cohort, XGBoost model showed acceptable discrimination (AUC: 0.701, 95 % CI: [0.655-0.746]), calibration (p-value of Hosmer-Lemeshow test > 0.05; good agreement on calibration plot), overall performance (Brier score: 0.200), and clinical usefulness (decision curve analysis: more net benefit than default strategies within the threshold of 0.15-0.80). The top 3 of 14 important predictors generally available in community were age, waist circumference and cognitive function. We embedded XGBoost model into the server and this (pre)frailty predictive system is accessible at http://www.frailtyprediction.com.cn. A nomogram was also conducted to enhance the practical use. Conclusions: A user-friendly web-based system was developed with good performance to assist healthcare providers to measure the probability of being (pre)frail among community-dwelling older adults in the next two years, facilitating the early identification of high-risk population of (pre)frailty. Further research is needed to validate this preliminary system across more controlled cohorts.

Consistency in the prevalence and associated factors of frailty determined by two instruments among hospitalised older adults: A cross‐sectional study

Article

Jun 2022

Aims and objectives: To investigate the consistency in the prevalence and associated factors of frailty determined by the physical-originated Fatigue, Resistance, Ambulation, Illnesses and Loss of weight (FRAIL) scale and the multidimensional Tilburg Frailty Indicators (TFI) scale. Background: Accurate assessment of frailty and the identification of its associated factors could guide the development and implementation of holistic and individualised treatment plan. However, recommendations regarding the selection of frailty assessment tools are inconclusive. Design: This is a cross-sectional study, the reporting of which followed the STROBE guidelines. Methods: A total of 1220 older adults were recruited from a university affiliated tertiary hospital in Xi'an City, Northwest China, and administrated with a social-demographic and health-related information sheet, the FRAIL, the TFI, the Short-Form Mini-Nutritional Assessment, the Pittsburgh Sleep Quality Index and the 5-level EuroQol 5 dimensions questionnaire. Descriptive statistics and binary logistic regression analysis were used to investigate the prevalence of frailty and its associated factors. Results: The prevalence of physical-originated and multidimensional frailty was 55.2% and 77.6%, respectively. The consistency between the two scales was low. Taking the combined use of the two instruments as the reference, the TFI and FRAIL could identify 89.99% and 64.02% of the participants with frailty. Polypharmacy, health-related quality of life and sleep quality were found to be associated with both physical-originated and multidimensional frailty. Nutritional status and level of physical activity were additionally identified as the independent associated factors of multidimensional frailty. Conclusions: The prevalence of frailty among hospitalised older adults is high. There is low consistency between the FRAIL and TFI in detecting frailty. The TFI exhibited higher sensitivity in detecting individuals with frailty and its associated factors. Relevance to clinical practice: The findings of this study supported a single use of the TFI for the assessment of frailty in the hospital setting.

Author's response to “Comment on Si et al. (2021) ‘Predictive performance of 7 frailty instruments for short-term disability, falls and hospitalization among Chinese community-dwelling older adults: A prospective cohort study’”

Article

May 2022
INT J NURS STUD

Diagnostic accuracy of the frail scale plus functional measures for frailty screening

Article

Full-text available

May 2022

Background There is little knowledge of the diagnostic accuracy of screening programmes for frailty in primary care settings. Aim To assess a two-step strategy consisting of the administration of the FRAIL scale to those who are non-dependent, aged ≥75 years, followed-up by measurement of the Short Physical Performance Battery (SPPB) or gait speed in those who are positive. Design & setting Cross-sectional and longitudinal cohort study. Analysis of primary care data from the FRAILTOOLS project at five European cities. Method All patients consecutively attending were enrolled. They received the index tests plus the Fried phenotype and the frailty index to assess their frailty status. Mortality and worsening of dependency in basic (BADL) and instrumental (IADL) activities of daily living over a year were ascertained. Results Prevalence of frailty based on frailty phenotype was 14.9% in the 362 participants. A FRAIL scale score ≥1 had a sensitivity of 83.3% (95%CI:73.1–93.6) to detect frailty. A positive result and a SPPB score <11 had a sensitivity of 72.2% (95%CI: 59.9–84.6); when combined with a gait speed <1.1 m/s, the sensitivity was 80% (95%CI: 68.5–91.5). Two thirds of those screened as positive were not frail. In the best scenario, sensitivities of this last combination to detect IADL and BADL worsening were 69.4% (95%CI: 59.4–79.4) and 63.6% (95%CI: 53.4–73.9). Conclusion Combining the FRAIL scale with other functional measures offers an acceptable screening approach for frailty. Accurate prediction of worsening dependency and death need to be confirmed through the piloting of a frailty screening programme.

Effects of social support on frailty trajectory classes among community-dwelling older adults: The mediating role of depressive symptoms and physical activity

Article

May 2022
GERIATR NURS

Objectives To investigate whether and how social support influenced frailty progression through depressive symptoms and physical activity. Methods Of 1235 community-dwelling older adults enrolled at baseline, 778 (63.0%) undergoing at least one yearly follow-up were included in the final analysis. Data were collected on frailty, social support, depressive symptoms, physical activity and covariates. Results Two frailty trajectory classes were identified and labeled as alleviated frailty and deteriorated frailty. Subjective support prevented the deterioration of frailty through decreased depressive symptoms, while objective support and support utilization prevented the deterioration of frailty through increased physical activity. Conclusions The pathways through which social support ameliorates frailty vary by support types. Subjective support interventions should be included in the multifactorial interdisciplinary management of frailty to address social and psychological vulnerabilities, along with objective support and support utilization interventions addressing physical inactivity.

The Tilburg Frailty Indicator: A Psychometric Systematic Review

Article

Full-text available

Feb 2022
AGEING RES REV

Background The Tilburg Frailty Indicator (TFI) is one of the most prominent multidimensional frailty assessment instruments. This review aimed to critically appraise and summarise its measurement properties. Methods Reports were eligible if they included results of studies aimed at developing the TFI or evaluating its measurement properties. We performed a literature search in MEDLINE, CINAHL, and PsycINFO databases from their inception until December 8, 2021. We also searched grey literature databases. We assessed the methodological quality of the included studies using the “COSMIN Risk of Bias”. The measurement properties were evaluated using specific criteria. We graded the quality of the evidence using a GRADE approach. Results Sixty-three studies were included. We found moderate sufficient evidence for TFI content validity, although it is still insufficient for the comprehensiveness of its items. TFI construct validity was based on sufficient evidence from two studies of its structural validity as well as multiple hypothesis-testing for construct validity studies with inconsistent results. We did not find any studies that assessed cross-cultural validity. Only one of TFI’s three dimensions showed sufficient evidence for the internal consistency of its scores, and results in test-retest reliability were inconsistent. The TFI showed high sufficient concurrent validity with the comprehensive geriatric assessment. We identified several studies assessing its predictive validity for adverse frailty-related outcomes, although most of the evidence from these studies was insufficient. We did not find any studies that assessed the responsiveness of TFI scores. Conclusions The TFI had evidence gaps in several relevant measurement properties. Further research is needed to strengthen its usefulness as a clinical decision-making tool.

Comment on Si et al (2021) “Predictive performance of 7 frailty instruments for short-term disability, falls and hospitalization among Chinese community-dwelling older adults: A prospective cohort study”

Article

Jul 2021
INT J NURS STUD

Clinically Significant Change: Revisited

Article

Full-text available

Jun 1992

David C. Speer

The relationship between statistically and clinically significant change has been enigmatic. Jacobson and Truax (1991) have proposed an important step toward rapprochement. However, their suggested index of clinically significant change neglects possible confounding of improvement rate estimates by regression to the mean. An alternative method is described that incorporates an adjustment that minimizes this confounding when statistical regression has been shown to be present. If regression is not present, the Jacobson and Truax method is more appropriate; if regression is present, the Edwards–Nunnally method (Edwards, Yarvis, Mueller, Zingale, & Wagman, 1978) is more appropriate. The two methods are compared, and the effects of instrument reliability and sample deviance on estimated improvement rates are demonstrated using general well-being test–retest data from a sample of older adult mental health outpatients.

Physical Frailty: ICFSR International Clinical Practice Guidelines for Identification and Management

Article

Full-text available

Oct 2019

Objective The task force of the International Conference of Frailty and Sarcopenia Research (ICFSR) developed these clinical practice guidelines to overview the current evidence-base and to provide recommendations for the identification and management of frailty in older adults. Methods These recommendations were formed using the GRADE approach, which ranked the strength and certainty (quality) of the supporting evidence behind each recommendation. Where the evidence-base was limited or of low quality, Consensus Based Recommendations (CBRs) were formulated. The recommendations focus on the clinical and practical aspects of care for older people with frailty, and promote person-centred care. Recommendations for Screening and Assessment The task force recommends that health practitioners case identify/screen all older adults for frailty using a validated instrument suitable for the specific setting or context (strong recommendation). Ideally, the screening instrument should exclude disability as part of the screening process. For individuals screened as positive for frailty, a more comprehensive clinical assessment should be performed to identify signs and underlying mechanisms of frailty (strong recommendation). Recommendations for Management A comprehensive care plan for frailty should address polypharmacy (whether rational or nonrational), the management of sarcopenia, the treatable causes of weight loss, and the causes of exhaustion (depression, anaemia, hypotension, hypothyroidism, and B12 deficiency) (strong recommendation). All persons with frailty should receive social support as needed to address unmet needs and encourage adherence to a comprehensive care plan (strong recommendation). First-line therapy for the management of frailty should include a multi-component physical activity programme with a resistance-based training component (strong recommendation). Protein/caloric supplementation is recommended when weight loss or undernutrition are present (conditional recommendation). No recommendation was given for systematic additional therapies such as cognitive therapy, problem-solving therapy, vitamin D supplementation, and hormone-based treatment. Pharmacological treatment as presently available is not recommended therapy for the treatment of frailty.

The ability of four frailty screening instruments to predict mortality, hospitalization and dependency in (instrumental) activities of daily living

Article

Full-text available

Sep 2019
EUR J AGEING

The aim of this study was to assess the predictive ability of the frailty phenotype (FP), Groningen Frailty Indicator (GFI), Tilburg Frailty Indicator (TFI) and frailty index (FI) for the outcomes mortality, hospitalization and increase in dependency in (instrumental) activities of daily living ((I)ADL) among older persons. This prospective cohort study with 2-year follow-up included 2420 Dutch community-dwelling older people (65+, mean age 76.3 ± 6.6 years, 39.5% male) who were pre-frail or frail according to the FP. Mortality data were obtained from Statistics Netherlands. All other data were self-reported. Area under the receiver operating characteristic curves (AUC) was calculated for each frailty instrument and outcome measure. The prevalence of frailty, sensitivity and specificity were calculated using cutoff values proposed by the developers and cutoff values one above and one below the proposed ones (0.05 for FI). All frailty instruments poorly predicted mortality, hospitalization and (I)ADL dependency (AUCs between 0.62–0.65, 0.59–0.63 and 0.60–0.64, respectively). Prevalence estimates of frailty in this population varied between 22.2% (FP) and 64.8% (TFI). The FP and FI showed higher levels of specificity, whereas sensitivity was higher for the GFI and TFI. Using a different cutoff point considerably changed the prevalence, sensitivity and specificity. In conclusion, the predictive ability of the FP, GFI, TFI and FI was poor for all outcomes in a population of pre-frail and frail community-dwelling older people. The FP and the FI showed higher values of specificity, whereas sensitivity was higher for the GFI and TFI.

Effectiveness of interventions to prevent pre-frailty and frailty progression in older adults: A systematic review

Article

Full-text available

Jan 2018

Objective: To summarize the best available evidence regarding the effectiveness of interventions for preventing frailty progression in older adults. Introduction: Frailty is an age-related state of decreased physiological reserves characterized by an increased risk of poor clinical outcomes. Evidence supporting the malleability of frailty, its prevention and treatment, has been presented. Inclusion criteria: The review considered studies on older adults aged 65 and over, explicitly identified as pre-frail or frail, who had been undergoing interventions focusing on the prevention of frailty progression. Participants selected on the basis of specific illness or with a terminal diagnosis were excluded. The comparator was usual care, alternative therapeutic interventions or no intervention. The primary outcome was frailty. Secondary outcomes included: (i) cognition, quality of life, activities of daily living, caregiver burden, functional capacity, depression and other mental health-related outcomes, self-perceived health and social engagement; (ii) drugs and prescriptions, analytical parameters, adverse outcomes and comorbidities; (iii) costs, and/or costs relative to benefits and/or savings associated with implementing the interventions for frailty. Experimental study designs, cost effectiveness, cost benefit, cost minimization and cost utility studies were considered for inclusion. Methods: Databases for published and unpublished studies, available in English, Portuguese, Spanish, Italian and Dutch, from January 2001 to November 2015, were searched. Critical appraisal was conducted using standardized instruments from the Joanna Briggs Institute. Data was extracted using the standardized tools designed for quantitative and economic studies. Data was presented in a narrative form due to the heterogeneity of included studies. Results: Twenty-one studies, all randomized controlled trials, with a total of 5275 older adults and describing 33 interventions, met the criteria for inclusion. Economic analyses were conducted in two studies. Physical exercise programs were shown to be generally effective for reducing or postponing frailty but only when conducted in groups. Favorable effects on frailty indicators were also observed after the interventions, based on physical exercise with supplementation, supplementation alone, cognitive training and combined treatment. Group meetings and home visits were not found to be universally effective. Lack of efficacy was evidenced for physical exercise performed individually or delivered one-to-one, hormone supplementation and problem solving therapy. Individually tailored management programs for clinical conditions had inconsistent effects on frailty prevalence. Economic studies demonstrated that this type of intervention, as compared to usual care, provided better value for money, particularly for very frail community-dwelling participants, and had favorable effects in some of the frailty-related outcomes in inpatient and outpatient management, without increasing costs. Conclusions: This review found mixed results regarding the effectiveness of frailty interventions. However, there is clear evidence on the usefulness of such interventions in carefully chosen evidence-based circumstances, both for frailty itself and for secondary outcomes, supporting clinical investment of resources in frailty intervention. Further research is required to reinforce current evidence and examine the impact of the initial level of frailty on the benefits of different interventions. There is also a need for economic evaluation of frailty interventions.

Predictive performance of four frailty screening tools in community-dwelling elderly

Article

Full-text available

Nov 2017
BMC Geriatr

Background This study compares the performance of four frailty screening tools in predicting relevant adverse outcome (disability, institutionalization and mortality) in community-dwelling elderly. Methods Our study involved a secondary analysis of data from the FréLE cohort study. We focused on the following four frailty screening tools: the abbreviated Comprehensive Geriatric Assessment (aCGA), the Groningen Frailty Indicator (GFI), the Vulnerable Elders Survey-13 (VES-13) and the Fried scale. We used the Barberger-Gateau scale to assess disability. For comparison, we determined the capacity of these tools to predict the occurrence of disability, institutionalization or death using the receiver operating characteristic (ROC) curve. We also determined the threshold at which an optimal balance between sensitivity and specificity was reached. Odds ratios (ORs) were calculated to compare the risk of adverse outcome in the frail versus non-frail groups. ResultsIn total, 1643 participants were included in the mortality analyses; 1224 participants were included in the analyses of the other outcomes (74.5% of the original sample). The mean age was 77.7 years, and 48.1% of the participants were women. The prevalence of frailty in this sample ranged from 15.0% (Fried) to 52.2% (VES-13). According to the Barberger-Gateau scale, 643 (52.5%) participants were fully independent; 392 (32.0%) were mildly disabled; 118 (9.6%) were moderately disabled; and 71 (5.8%) were severely disabled. The tool with the greatest sensitivity for predicting the occurrence of disability, mortality and institutionalization was VES-13, which showed sensitivities of 91.0%, 89.7% and 92.3%, respectively. The values for the area under the curve (AUC) of the four screening tools at the proposed cut-off points ranged from 0.63 to 0.75. The odds (univariate and multivariate analysis) of developing a disability were significantly greater among the elderly identified as being frail by all four tools. Conclusion The multivariate analyses showed that the VES-13 may predict the occurrence of disability, mortality and institutionalization. However, the AUC analysis showed that even this tool did not have good discriminatory ability. These findings suggest that despite the high number of frailty screening tools described in the literature, there is still a need for a screening tool with high predictive performance.

Use of the electronic Frailty Index to identify vulnerable patients: A pilot study in primary care

Article

Full-text available

Sep 2017

Background: Identifying frailty is key to providing appropriate treatment for older people at high risk of adverse health outcomes. Screening tools proposed for primary care often involve additional workload. The electronic Frailty Index (eFI) has the potential to overcome this issue. Aim: To assess the feasibility and acceptability of using the eFI in primary care. Design and setting: Pilot study in one suburban primary care practice in southern England in 2016. Method: Use of the eFI on the primary care TPP SystmOne database was explained to staff at the practice where a comprehensive geriatric assessment (CGA) clinic was being trialled. The practice data manager ran an eFI report for all patients (n = 6670). Date of birth was used to identify patients aged ≥75 years (n = 589). The eFI was determined for patients attending the CGA clinic (n = 18). Results: Practice staff ran the eFI reports in 5 minutes, which they reported was feasible and acceptable. The eFI range was 0.03 to 0.61 (mean 0.23) for all patients aged ≥75 years (mean 83 years, range 75 to 102 years). For CGA patients (mean 82 years, range 75 to 94 years) the eFI range was 0.19 to 0.53 (mean 0.33). Importantly, the eFI scores identified almost 12% of patients aged ≥75 years in this practice to have severe frailty. Conclusion: It was feasible and acceptable to use the eFI in this pilot study. A higher mean eFI in the CGA patients demonstrated construct validity for frailty identification. Practice staff recognised the potential for the eFI to identify the top 2% of vulnerable patients for avoiding unplanned admissions.

The Asia-Pacific Clinical Practice Guidelines for the Management of Frailty

Article

Full-text available

Jul 2017

Objective To develop Clinical Practice Guidelines for the screening, assessment and management of the geriatric condition of frailty. Methods An adapted Grading of Recommendations, Assessment, Development, and Evaluation approach was used to develop the guidelines. This process involved detailed evaluation of the current scientific evidence paired with expert panel interpretation. Three categories of Clinical Practice Guidelines recommendations were developed: strong, conditional, and no recommendation. Recommendations Strong recommendations were (1) use a validated measurement tool to identify frailty; (2) prescribe physical activity with a resistance training component; and (3) address polypharmacy by reducing or deprescribing any inappropriate/superfluous medications. Conditional recommendations were (1) screen for, and address modifiable causes of fatigue; (2) for persons exhibiting unintentional weight loss, screen for reversible causes and consider food fortification and protein/caloric supplementation; and (3) prescribe vitamin D for individuals deficient in vitamin D. No recommendation was given regarding the provision of a patient support and education plan. Conclusions The recommendations provided herein are intended for use by healthcare providers in their management of older adults with frailty in the Asia Pacific region. It is proposed that regional guideline support committees be formed to help provide regular updates to these evidence-based guidelines.

Prevalence and Correlates of Frailty Among Community-Dwelling Chinese Older Adults: The China Health and Retirement Longitudinal Study

Article

Full-text available

May 2017
J GERONTOL A-BIOL

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.

Comparison of 10 single and stepped methods to identify frail older persons in primary care: Diagnostic and prognostic accuracy

Article

Full-text available

Aug 2016
BMC FAM PRACT

Background: Many instruments have been developed to identify frail older adults in primary care. A direct comparison of the accuracy and prevalence of identification methods is rare and most studies ignore the stepped selection typically employed in routine care practice. Also it is unclear whether the various methods select persons with different characteristics. We aimed to estimate the accuracy of 10 single and stepped methods to identify frailty in older adults and to predict adverse health outcomes. In addition, the methods were compared on their prevalence of the identified frail persons and on the characteristics of persons identified. Methods: The Groningen Frailty Indicator (GFI), the PRISMA-7, polypharmacy, the clinical judgment of the general practitioner (GP), the self-rated health of the older adult, the Edmonton Frail Scale (EFS), the Identification Seniors At Risk Primary Care (ISAR PC), the Frailty Index (FI), the InterRAI screener and gait speed were compared to three measures: two reference standards (the clinical judgment of a multidisciplinary expert panel and Fried's frailty criteria) and 6-years mortality or long term care admission. Data were used from the Dutch Identification of Frail Elderly Study, consisting of 102 people aged 65 and over from a primary care practice in Amsterdam. Frail older adults were oversampled. The accuracy of each instrument and several stepped strategies was estimated by calculating the area under the ROC-curve. Results: Prevalence rates of frailty ranged from 14.8 to 52.9 %. The accuracy for recommended cut off values ranged from poor (AUC = 0.556 ISAR-PC) to good (AUC = 0.865 gait speed). PRISMA-7 performed best over two reference standards, GP predicted adversities best. Stepped strategies resulted in lower prevalence rates and accuracy. Persons selected by the different instruments varied greatly in age, IADL dependency, receiving homecare and mood. Conclusion: We found huge differences between methods to identify frail persons in prevalence, accuracy and in characteristics of persons they select. A necessary next step is to find out which frail persons can benefit from intervention before case finding programs are implemented. Further evidence is needed to guide this emerging clinical field.

Do commonly used frailty models predict mortality, loss of autonomy and mental decline in older adults in northwestern Russia? A prospective cohort study

Article

Full-text available

May 2016
BMC Geriatr

Background Frailty prevalence differs across countries depending on the models used to assess it that are based on various conceptual and operational definitions. This study aims to assess the clinical validity of three frailty models among community-dwelling older adults in north-western Russia where there is a higher incidence of cardiovascular disease and lower life expectancy than in European countries. Methods The Crystal study is a population-based prospective cohort study in Kolpino, St. Petersburg, Russia. A random sample of the population living in the district was stratified into two age groups: 65–75 (n = 305) and 75+ (n = 306) and had a baseline comprehensive health assessment followed by a second one after 33.4 +/−3 months. The total observation time was 47 +/−14.6 months. Frailty was assessed according to the models of Fried, Puts and Steverink-Slaets. Its association with mortality at 5 years follow-up as well as dependency, mental and physical decline at around 2.5 years follow up was explored by multivariable and time-to-event analyses. Results Mortality was predicted independently from age, sex and comorbidities only by the frail status of the Fried model in those over 75 years old [HR (95 % CI) = 2.50 (1.20–5.20)]. Mental decline was independently predicted only by pre-frail [OR (95 % CI) = 0.24 (0.10–0.55)] and frail [OR (95 % CI) = 0.196 (0.06–0.67)] status of Fried model in those 65–75 years old. The prediction of dependency and physical decline by pre-frail and frail status of any the three frailty models was not statistically significant in this cohort of older adults. Conclusions None of the three frailty models was valid at predicting 5 years mortality and disability, mental and physical decline at 2.5 years in a cohort of older adults in north-west Russia. Frailty by the Fried model had only limited value for mortality in those 75 years old and mental decline in those 65–75 years old. Further research is needed to identify valid frailty markers for older adults in this population.

A Multicomponent Exercise Intervention that Reverses Frailty and Improves Cognition, Emotion, and Social Networking in the Community-Dwelling Frail Elderly: A Randomized Clinical Trial

Article

Full-text available

Mar 2016

Background: Frailty can be an important clinical target to reduce rates of disability. Objective: To ascertain if a supervised-facility multicomponent exercise program (MEP) when performed by frail older persons can reverse frailty and improve functionality; cognitive, emotional, and social networking; as well as biological biomarkers of frailty, when compared with a controlled population that received no training. Design: This is an interventional, controlled, simple randomized study. Researchers responsible for data gathering were blinded for this study. Setting: Participants from 2 primary rural care centers (Sollana and Carcaixent) of the same health department in Spain were enrolled in the study between December 2013 and September 2014. Patients: We randomized a volunteer sample of 100 men and women who were sedentary, with a gait speed lower than 0.8 meters per second and frail (met at least 3 of the frailty phenotype criteria). Interventions: Participants were randomized to a supervised-facility MEP (n = 51, age = 79.5, SD 3.9) that included proprioception, aerobic, strength, and stretching exercises for 65 minutes, 5 days per week, 24 weeks, or to a control group (n = 49, age = 80.3, SD 3.7). The intervention was performed by 8 experienced physiotherapists or nurses. Protein-calorie and vitamin D supplementation were controlled in both groups. Results: Our MEP reverses frailty (number needed to treat to recover robustness in subjects with attendance to ≥50% of the training sessions was 3.2) and improves functional measurements: Barthel (trained group 91.6 SD 8.0 vs 82.0 SD 11.0 control group), Lawton and Brody (trained group 6.9 SD 0.9 vs 5.7 SD 2.0 control group), Tinetti (trained group 24.5 SD 4.4 vs 21.7 SD 4.5 control group), Short Physical Performance Battery (trained group 9.5 SD 1.8 vs 7.1 SD 2.8 control group), and physical performance test (trained group 23.5 SD 5.9 vs 16.5 SD 5.1 control group) as well as cognitive, emotional, and social networking determinations: Mini-Mental State Examination (trained group 28.9 SD 3.9 vs 25.9 SD 7.3 control group), geriatric depression scale from Yesavage (trained group 2.3 SD 2.2 vs 3.2 SD 2.0 control group), EuroQol quality-of-life scale (trained group 8.2 SD 1.6 vs 7.6 SD 1.3 control group), and Duke social support (trained group 48.5 SD 9.3 vs 41.2 SD 8.5 control group). This program is unique in that it leads to a decrease in the number of visits to primary care physician (trained group 1.3 SD 1.4 vs 2.4 SD 2.9 control group) and to a significant improvement in frailty biomarkers. Conclusions: We have designed a multicomponent exercise intervention that reverses frailty and improves cognition, emotional, and social networking in a controlled population of community-dwelling frail older adults. Trial registration: ClinicalTrials.gov. Identifier: NCT02331459.

Development and validation of an electronic frailty index using routine primary care electronic health record data

Article

Full-text available

Mar 2016
AGE AGEING

Background: frailty is an especially problematic expression of population ageing. International guidelines recommend routine identification of frailty to provide evidence-based treatment, but currently available tools require additional resource. Objectives: to develop and validate an electronic frailty index (eFI) using routinely available primary care electronic health record data. Study design and setting: retrospective cohort study. Development and internal validation cohorts were established using a randomly split sample of the ResearchOne primary care database. External validation cohort established using THIN database. Participants: patients aged 65–95, registered with a ResearchOne or THIN practice on 14 October 2008. Predictors: we constructed the eFI using the cumulative deficit frailty model as our theoretical framework. The eFI score is calculated by the presence or absence of individual deficits as a proportion of the total possible. Categories of fit, mild, moderate and severe frailty were defined using population quartiles. Outcomes: outcomes were 1-, 3- and 5-year mortality, hospitalisation and nursing home admission. Statistical analysis: hazard ratios (HRs) were estimated using bivariate and multivariate Cox regression analyses. Discrimination was assessed using receiver operating characteristic (ROC) curves. Calibration was assessed using pseudo-R² estimates. Results: we include data from a total of 931,541 patients. The eFI incorporates 36 deficits constructed using 2,171 CTV3 codes. One-year adjusted HR for mortality was 1.92 (95% CI 1.81–2.04) for mild frailty, 3.10 (95% CI 2.91–3.31) for moderate frailty and 4.52 (95% CI 4.16–4.91) for severe frailty. Corresponding estimates for hospitalisation were 1.93 (95% CI 1.86–2.01), 3.04 (95% CI 2.90–3.19) and 4.73 (95% CI 4.43–5.06) and for nursing home admission were 1.89 (95% CI 1.63–2.15), 3.19 (95% CI 2.73–3.73) and 4.76 (95% CI 3.92–5.77), with good to moderate discrimination but low calibration estimates. Conclusions: the eFI uses routine data to identify older people with mild, moderate and severe frailty, with robust predictive validity for outcomes of mortality, hospitalisation and nursing home admission. Routine implementation of the eFI could enable delivery of evidence-based interventions to improve outcomes for this vulnerable group.

Frailty Assessment Instruments: Systematic Characterization of the Uses and Contexts of Highly-Cited Instruments

Article

Full-text available

Mar 2016

The medical syndrome of frailty is widely recognized, yet debate remains over how best to measure it in clinical and research settings. This study reviewed the frailty-related research literature by a) comprehensively cataloging the wide array of instruments that have been utilized to measure frailty, and b) systematically categorizing the different purposes and contexts of use for frailty instruments frequently cited in the research literature. We identified 67 frailty instruments total; of these, nine were highly-cited (≥200 citations). We randomly sampled and reviewed 545 English-language articles citing at least one highly-cited instrument. We estimated the total number of uses, and classified use into eight categories: risk assessment for adverse health outcomes (31% of all uses); etiological studies of frailty (22%); methodology studies (14%); biomarker studies (12%); inclusion/exclusion criteria (10%); estimating prevalence as primary goal (5%); clinical decision-making (2%); and interventional targeting (2%). The most common assessment context was observational studies of older community-dwelling adults. Physical Frailty Phenotype was the most used frailty instrument in the research literature, followed by the Deficit Accumulation Index and the Vulnerable Elders Survey. This study provides an empirical review of the current uses of frailty instruments, which may be important to consider when selecting instruments for clinical or research purposes. We recommend careful consideration in the selection of a frailty instrument based on the intended purpose, domains captured, and how the instrument has been used in the past. Continued efforts are needed to study the validity and feasibility of these instruments.

Frailty as a predictor of short-term adverse outcomes

Article

Full-text available

Jul 2015

The objectives of this study were to compare how different frailty measures (Frailty Phenotype/FP, Groningen Frailty Indicator/GFI and Tilburg Frailty Indicator/TFI) predict short-term adverse outcomes. Secondarily, adopting a multidimensional approach to frailty (integral conceptual model–TFI), this study aims to compare how physical, psychological and social frailty predict the outcomes. A longitudinal study was carried out with 95 community-dwelling elderly. Participants were assessed at baseline for frailty, determinants of frailty, and adverse outcomes (healthcare utilization, quality of life, disability in basic and instrumental activities of daily living/ADL and IADL). Ten months later the outcomes were assessed again. Frailty was associated with specific healthcare utilization indicators: the FP with a greater utilization of informal care; GFI with an increased contact with healthcare professionals; and TFI with a higher amount of contacts with a general practitioner. After controlling for the effect of life-course determinants, comorbidity and adverse outcome at baseline, GFI predicted IADL disability and TFI predicted quality of life. The effect of the FP on the outcomes was not significant, when compared with the other measures. However, when comparing TFI’s domains, the physical domain was the most significant predictor of the outcomes, even explaining part of the variance of ADL disability. Frailty at baseline was associated with adverse outcomes at follow-up. However, the relationship of each frailty measure (FP, GFI and TFI) with the outcomes was different. In spite of the role of psychological frailty, TFI’s physical domain was the determinant factor for predicting disability and most of the quality of life.

Nutritional, Physical, Cognitive, and Combination Interventions and Frailty Reversal Among Older Adults: A Randomized Controlled Trial

Article

Full-text available

Jul 2015

It is important to establish whether frailty among older individuals is reversible with nutritional, physical or cognitive interventions, singly or in combination. We compared the effects of 6-month duration interventions with nutritional supplementation, physical training, cognitive training, and combination treatment versus control in reducing frailty among community-dwelling pre-frail and frail older persons. We conducted a parallel group, randomized controlled trial in community-living pre-frail and frail old adults in Singapore. The participants' mean age was 70.0 years, and 61.4% (n=151) were female. Five different 6-month interventions included nutritional supplementation (N=49), cognitive training (N=50), physical training (N=48), combination treatment (N=49) and usual care control (N=50). Frailty score, body mass index, knee extension strength, gait speed, energy/vitality, and physical activity levels and secondary outcomes (activities of daily living dependency, hospitalization and falls) were assessed at 0 month, 3 month, 6 month and 12 month. Frailty score and status over 12 months were reduced in all groups, including control (15%), but were significantly higher (35.6% to 47.8%) in the nutritional (OR=2.98), cognition (OR=2.89) and physical (OR=4.05) and combination (OR=5.00) intervention groups. Beneficial effects were observed at 3 month and 6 month, and persisted at 12 month. Improvements in physical frailty domains (associated with interventions) were most evident for knee strength (physical, cognitive and combination treatment), physical activity (nutritional intervention), gait speed (physical intervention), and energy (combination intervention). There were no major differences with respect to the small numbers of secondary outcomes. Physical, nutritional and cognitive interventional approaches were effective in reversing frailty among community-living older persons. Copyright © 2015 Elsevier Inc. All rights reserved.

Tilburg frailty indicator : German translation and psychometric testing

Article

Full-text available

May 2015
Z GERONTOL GERIATR

The Tilburg frailty indicator (TFI) is a self-report measurement instrument which integrates the physical, psychological and social domains to assess frailty in older adults. The aim of this study was the adaptation of the TFI to a German version and testing of the psychometric properties. This study surveyed 210 individuals aged 64-91 years living at home. The mean age of participants was M = 75.3±5.7 years with 62 % females. The internal consistency was tested with Cronbach's alpha. The test-retest reliability was calculated after 20 weeks. The German TFI was validated using alternative measures for assessment of the quality of life, e.g. Eurohis-QoL-8 and short form health survey (SF-12), the patient health questionnaire (PHQ), the geriatric anxiety inventory short form (GAI-SF), the social support scale (F-Soz-U-K-14) and the resilience scale (RS-11). The internal consistency was acceptable with a value for Cronbach's alpha of 0.67. The test-retest reliability was good after 5 months α = 0.87 (physical domain r = 0.85, psychological domain r = 0.75 and social domain r = 0.84). The inter-item correlations ranged between - 0.06 and 0.57. Correlations with alternative frailty measures showed good convergent and divergent validity. This study showed acceptable psychometric properties of the German adaptation of the TFI which was found to be age and frailty sensitive. The results of the validity of the TFI support the three domains integrated in the frailty score. Further application and testing of the German TFI in primary care and clinical settings are suggested to consolidate the findings.

Effects of Exercise and Milk Fat Globule Membrane (MFGM) Supplementation on Body Composition, Physical Function, and Hematological Parameters in Community-Dwelling Frail Japanese Women: A Randomized Double Blind, Placebo-Controlled, Follow-Up Trial

Article

Full-text available

Feb 2015
PLOS ONE

OBJECTIVE:To investigate the combined and separate effects of exercise and milk fat globule membrane (MFGM) supplementation on frailty, physical function, physical activity level, and hematological parameters in community-dwelling elderly Japanese women. METHODS:A total of 131 frail, elderly women over 75 years were randomly assigned to one of four groups: exercise and MFGM supplementation (Ex+MFGM), exercise and placebo (Ex+Plac), MFGM supplementation, or the placebo group. The exercise group attended a 60-minute training program twice a week for three months, and the MFGM group ingested 1g of the MFGM supplement in pill form, daily for 3 months. The primary outcome measure was change in frailty status based on Fried's frailty phenotype. Secondary outcome measures included body composition, physical function and hematological parameters, and interview survey components assessing lifestyle factors. Participants were followed for 4 months post-intervention. RESULTS:Significant group × time interactions were observed for usual walking speed (P = 0.005), timed up & go (P

Best practice guidelines for the management of frailty: A British Geriatrics Society, Age UK and Royal College of General Practitioners report

Article

Full-text available

Nov 2014
AGE AGEING

Unlabelled: Older people are majority users of health and social care services in the UK and internationally. Many older people who access these services have frailty, which is a state of vulnerability to adverse outcomes. The existing health care response to frailty is mainly secondary care-based and reactive to the acute health crises of falls, delirium and immobility. A more proactive, integrated, person-centred and community-based response to frailty is required. The British Geriatrics Society Fit for Frailty guideline is consensus best practice guidance for the management of frailty in community and outpatient settings. Recognition of frailty: The BGS recommends that all encounters between health and social care staff and older people in community and outpatient settings should include an assessment for frailty. A gait speed <0.8m/s; a timed-up-and-go test >10s; and a score of ≥3 on the PRISMA 7 questionnaire can indicate frailty. The common clinical presentations of frailty (falls, delirium, sudden immobility) can also be used to indicate the possible presence of frailty. Management of frailty: The BGS recommends an holistic medical review based on the principles of comprehensive geriatric assessment (CGA) for all older people identified with frailty. This will: diagnose medical illnesses to optimise treatment; apply evidence-based medication review checklists (e.g. STOPP/START criteria); include discussion with older people and carers to define the impact of illness; work with the older person to create an individualised care and support plan. Screening for frailty: The BGS does not recommend population screening for frailty using currently available instruments.

Cross-cultural adaptation and reliability testing of the Tilburg Frailty Indicator for optimizing care of Polish patients with frailty syndrome

Article

Full-text available

Jun 2014

Background Frail older people are at high risk of developing adverse outcomes, such as disability, mortality, hospitalization, and institutionalization. Previous research suggests that the Tilburg Frailty Indicator (TFI) is a valid and reliable instrument for measuring frailty. The aim of this study was to adapt and to test the reliability of the Polish version of the TFI. Method A standard guideline was used for translation and cultural adaptation of the English version of the TFI into Polish. The study included 100 Polish patients (mean age 68.2±6.5 years), among them 42 men and 58 women. Cronbach’s alpha was used for analysis of the internal consistency of the TFI. Results The mean total TFI score was 6.7±3.1. Forty patients scored ≥5, which corresponded to being frail. Cronbach’s alpha reliability coefficients of the instrument ranged from 0.68 to 0.72 and item-total correlation ranged from 0.12 to 0.52. Conclusion The TFI is valid and reproducible for assessment of frailty syndrome among a Polish population. The Polish adaptation of the TFI proved a useful and fast tool for assessing frailty.

The psychometric qualities of the Groningen Frailty Indicator in Romanian community-dwelling old citizens

Article

Full-text available

May 2014
FAM PRACT

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.

Multidimensional structure of the Groningen Frailty Indicator in community-dwelling older people

Article

Full-text available

Aug 2013
BMC Geriatr

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.

Statistics Notes: Diagnostic tests 2: Predictive values

Article

Full-text available

Jul 1994

The whole point of a diagnostic test is to use it to make a diagnosis, so we need to know the probability that the test will give the correct diagnosis. The sensitivity and specificity1 do not give us this information. Instead we must approach the data from the direction of the test results, using predictive values. Positive predictive value is the proportion of patients with positive test results who are correctly diagnosed. Negative predictive value is the proportion of patients with negative test results who are correctly diagnosed. Using the same data as in the previous note,1 we know that 231 of 263 patients with abnormal liver scans had abnormal pathology, giving the proportion of correct diagnoses as 231/263 = 0.88. …

Cross-cultural adaptation and psychometric properties of the Groningen Frailty Indicator (GFI) among Chinese community-dwelling older adults

Article

Oct 2019

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.

Management of frailty: opportunities, challenges, and future directions

Article

Oct 2019

Frailty is a complex age-related clinical condition characterised by a decline in physiological capacity across several organ systems, with a resultant increased susceptibility to stressors. Because of the heterogeneity of frailty in clinical presentation, it is important to have effective strategies for the delivery of care that range across the continuum of frailty severity. In clinical practice, we should do what works, starting with frailty screening, case identification, and management of frailty. This process is unarguably difficult given the absence of an adequate evidence base for individual and health-system interventions to manage frailty. We advocate change towards individually tailored interventions that preserve an individual’s independence, physical function, and cognition. This change can be addressed by promoting the recognition of frailty, furthering advancements in evidence-based treatment options, and identifying cost-effective care delivery strategies.

Frailty: implications for clinical practice and public health

Article

Oct 2019

Frailty is an emerging global health burden, with major implications for clinical practice and public health. The prevalence of frailty is expected to rise alongside rapid growth in the ageing population. The course of frailty is characterised by a decline in functioning across multiple physiological systems, accompanied by an increased vulnerability to stressors. Having frailty places a person at increased risk of adverse outcomes, including falls, hospitalisation, and mortality. Studies have shown a clear pattern of increased health-care costs and use associated with frailty. All older adults are at risk of developing frailty, although risk levels are substantially higher among those with comorbidities, low socioeconomic position, poor diet, and sedentary lifestyles. Lifestyle and clinical risk factors are potentially modifiable by specific interventions and preventive actions. The concept of frailty is increasingly being used in primary, acute, and specialist care. However, despite efforts over the past three decades, agreement on a standard instrument to identify frailty has not yet been achieved. In this Series paper, we provide an overview of the global impact and burden of frailty, the usefulness of the frailty concept in clinical practice, potential targets for frailty prevention, and directions that need to be explored in the future.

Prevalence and Risk Factors for Frailty Among Community-Dwelling Older People in China: A Systematic Review and Meta-Analysis

Article

Mar 2019

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.

Should we screen for frailty in primary care settings? A fresh perspective on the frailty evidence base: A narrative review

Article

Dec 2018

With older adults living longer, health service providers have increasingly turned their attention towards frailty and its significant consequences for health and well-being. Consequently, frailty screening has gained momentum as a possible health policy answer to the question of what can be done to prevent frailty's onset and progression. However, who should be screened for frailty, where and when remains a subject of extensive debate. The purpose of this narrative review is to explore the dimensions of this question with reference to Wilson and Jungner's time-tested and widely accepted principles for acceptable screening within community settings. Although the balance of the emerging evidence to support frailty screening is promising, significant gaps in the evidence base remain. Consequently, when assessed against Wilson and Jungner's principles, extensive population screening does not appear to be supported by the evidence. However, screening for the purpose of case-finding may prove useful among older adults.

Cross-cultural adaptation and validation of the Comprehensive Frailty Assessment Instrument in Chinese community-dwelling older adults: Validation of the Chinese CFAI

Article

Oct 2017

Aim: To cross-culturally adapt and validate the Comprehensive Frailty Assessment Instrument (CFAI) among Chinese community-dwelling older adults. Methods: The Chinese CFAI was developed through forward-backward translations. An urban sample of 1235 community-dwelling older adults received face-to-face interviews to examine the validity (construct validity and criterion validity) and reliability (internal consistency and test-retest reliability). Results: The Chinese CFAI achieved semantic and idiomatic equivalence, and showed acceptable reliability and an expected factor structure, except for the social support domain. The exploratory factor analysis extracted five factors explaining 53.8% of the total variance of frailty. The confirmatory factor analysis showed that the data fit well to the second-order factor theoretical model, with a root mean square error of approximation of 0.05, Tucker-Lewis Index of 0.93 and Comparative Fit Index of 0.95. The receiver operating characteristic analysis presented an acceptable criterion validity using the Rockwood Frailty Index as an external criterion (area under the curve 0.80), with balanced sensitivity (65.31%) and specificity (81.19%) at the optimal 39-point frailty cut-off of the CFAI. Conclusions: The Chinese CFAI has good validity and reliability as a practical frailty measure in Chinese community-dwelling older adults.

Frailty as a Risk Factor for Falls Among Community Dwelling People: Evidence From a Meta-Analysis: Falls With Frailty

Article

Jul 2017
J NURS SCHOLARSHIP

Purpose: This study was conducted to investigate the relationships between different frailty stages and the fall incidence rates of community-dwelling older adults. The differences between various frailty indicators regarding assessment accuracy of the fall incidence rates of community-dwelling elders were also analyzed. Finally, the relationship between frailty and recurrent falls was explored. Methods: This study comprised a systematic literature review and meta-analysis. Two researchers independently examined and extracted the related literature. The key search terms included frailty, frail, fall, older people, older, geriatric, and senior. The literature sampling period was from January 2001 to December 2016. The quality of each paper was assessed according to the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The databases of the Cochrane Library, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PubMed, and MEDLINE were used to conduct a systematic literature search by using the random effect mode to analyze the compiled papers. Findings: A total of 102,130 community-dwelling older adults ≥65 years of age and 33,503 older adults who had experienced a fall were compiled to investigate the relationship between frailty and falls. The meta-analysis results revealed that compared with robust older adults, frail older adults demonstrated the greatest risk for falls, followed by prefrail older adults. Furthermore, the use of different frailty indicators to predict the fall incidence rates of older adults yielded nonsignificantly different outcomes. In short, studies of either cardiovascular health or osteoporotic fracture indicators are effective for predicting the risk for falls in older people. Finally, this study confirmed that compared with robust older adults, frail older adults were more likely to experience recurrent falls. Conclusions: Frailty is a crucial healthcare topic of people with geriatric syndromes. Frail older adults are likely to experience recurrent falls. In addition, the evidence-based study indicated that once older people enter the prefrail stage, they are likely to experience falls. Therefore, older adults should be evaluated for the possibility of geriatric syndromes such as frailty, which may be addressed to reduce the risk for bone fractures and death. Clinical relevance: Professional nurses should use frailty assessment indicators as early as possible to evaluate the possibility of frailty in community-dwelling older people. Meanwhile, effective frailty prevention strategies should be applied to prevent frailty, thereby reducing the incidence of falls and enhancing older persons' quality of life.

Cross-Cultural Adaptation and Validation of the FRAIL Scale in Chinese Community-Dwelling Older Adults

Article

Jul 2017

Objective: To cross-culturally adapt and test the FRAIL scale in Chinese community-dwelling older adults. Design: Cross-sectional study. Methods: The Chinese FRAIL scale was generated by translation and back-translation. An urban sample of 1235 Chinese community-dwelling older adults was enrolled to test its psychometric properties, including convergent validity, criterion validity, known-group divergent validity, internal consistency and test-retest reliability. Results: The Chinese FRAIL scale achieved semantic, idiomatic, and experiential equivalence. The convergent validity was confirmed by statistically significant kappa coefficients (0.209-0.401, P < .001) of each item with its corresponding alternative measurement, including the 7th item of the Center for Epidemiologic Studies-Depression Scale, the Timed Up and Go test, 4-m walking speed, polypharmacy, and the Short-Form Mini Nutritional Assessment. Using the Fried frailty phenotype as an external criterion, the Chinese FRAIL scale showed satisfactory diagnostic accuracy for frailty (area under the curve = 0.91). The optimal cut-point for frailty was 2 (sensitivity: 86.96%, specificity: 85.64%). The Chinese FRAIL scale had fair agreement with the Fried frailty phenotype (kappa = 0.274, P < .001), and classified more participants into frailty (17.2%) than the Fried frailty phenotype (3.9%). More frail individuals were recognized by the Chinese FRAIL scale among older and female participants than their counterparts (P < .001), respectively. It had low internal consistency (Kuder-Richardson formula 20 = 0.485) and good test-retest reliability within a 7- to 15-day interval (intraclass correlation coefficient = 0.708). Conclusions: The Chinese FRAIL scale presents acceptable validity and reliability and can apply to Chinese community-dwelling older adults.

Reliability and validity of the Tilburg Frailty Indicator (TFI) among Chinese community-dwelling older people

Article

Jul 2017

Objective: To translate the Tilburg Frailty Indicator (TFI) into Chinese and assess its reliability and validity. Methods: A sample of 917 community-dwelling older people, aged ≥60 years, in a Chinese city was included between August 2015 and March 2016. Construct validity was assessed using alternative measures corresponding to the TFI items, including self-rated health status (SRH), unintentional weight loss, walking speed, timed-up-and-go tests (TUGT), making telephone calls, grip strength, exhaustion, Short Portable Mental Status Questionnaire (SPMSQ), Geriatric Depression scale (GDS-15), emotional role, Adaptability Partnership Growth Affection and Resolve scale (APGAR) and Social Support Rating Scale (SSRS). Fried's phenotype and frailty index were measured to evaluate criterion validity. Adverse health outcomes (ADL and IADL disability, healthcare utilization, GDS-15, SSRS) were used to assess predictive (concurrent) validity. Results: The internal consistency reliability was good (Cronbach's α=0.71). The test-retest reliability was strong (r=0.88). Kappa coefficients showed agreements between the TFI items and corresponding alternative measures. Alternative measures correlated as expected with the three domains of TFI, with an exclusion that alternative psychological measures had similar correlations with psychological and physical domains of the TFI. The Chinese TFI had excellent criterion validity with the AUCs regarding physical phenotype and frailty index of 0.87 and 0.86, respectively. The predictive (concurrent) validities of the adverse health outcomes and healthcare utilization were acceptable (AUCs: 0.65-0.83). Conclusions: The Chinese TFI has good validity and reliability as an integral instrument to measure frailty of older people living in the community in China.

Comparing the predictive value of three definitions of frailty: Results from the Three-City study

Article

Jun 2017

Background Despite several attempts to reach a single definition of frailty, no consensus has been reached. The definitions previously published have tried to prove its utility in predicting negative health outcomes. The objective of the present study is to compare the predictive value of 3 different frailty instruments, for selected outcomes. Methods The study sample includes 1278 participants of the Three-City study, a French prospective population-based study, assessed for frailty using Fried's phenotype criteria, Rockwood's Frailty Index and Tilburg Frailty Indicator. To assess the risk of mortality, incident disability, falls, institutionalization and hospitalization for a follow up period of 12 years, Cox proportional hazard models with delayed entry have been used. The area under the time-dependent ROC curve has been used to estimate and compare the ability of the three instruments of frailty to predict the previous adverse outcomes at 12 years. Results Five hundred ninety four participants were identified as non-robust with Fried's criteria; 169 with Rockwood's FI and 303 with TFI. The three scales consistently identified 91 participants as non-robust and 574 as robust. Rockwood's FI was a statistically significant predictor of mortality, incident disability and falls, and a strong predictor of hospitalization. Conclusion In the absence of a “gold standard” definition of frailty, a debate on what measures and how to include them is open. A clue may be that one should select the appropriate definition according to the to-be predicted outcome, the setting and the underlying etiology of frailty.

Predicting risk and outcomes for frail older adults: an umbrella review of frailty screening tools

Article

Apr 2017

Background: A scoping search identified systematic reviews on diagnostic accuracy and predictive ability of frailty measures in older adults. In most cases, research was confined to specific assessment measures related to a specific clinical model. Objectives: To summarize the best available evidence from systematic reviews in relation to reliability, validity, diagnostic accuracy and predictive ability of frailty measures in older adults. Inclusion criteria Population: Older adults aged 60 years or older recruited from community, primary care, long-term residential care and hospitals. Index test: Available frailty measures in older adults. Reference test: Cardiovascular Health Study phenotype model, the Canadian Study of Health and Aging cumulative deficit model, Comprehensive Geriatric Assessment or other reference tests. Diagnosis of interest: Frailty defined as an age-related state of decreased physiological reserves characterized by an increased risk of poor clinical outcomes. Types of studies: Quantitative systematic reviews. Search strategy: A three-step search strategy was utilized to find systematic reviews, available in English, published between January 2001 and October 2015. Methodological quality: Assessed by two independent reviewers using the Joanna Briggs Institute critical appraisal checklist for systematic reviews and research synthesis. Data extraction: Two independent reviewers extracted data using the standardized data extraction tool designed for umbrella reviews. Data synthesis: Data were only presented in a narrative form due to the heterogeneity of included reviews. Results: Five reviews with a total of 227,381 participants were included in this umbrella review. Two reviews focused on reliability, validity and diagnostic accuracy; two examined predictive ability for adverse health outcomes; and one investigated validity, diagnostic accuracy and predictive ability. In total, 26 questionnaires and brief assessments and eight frailty indicators were analyzed, most of which were applied to community-dwelling older people. The Frailty Index was examined in almost all these dimensions, with the exception of reliability, and its diagnostic and predictive characteristics were shown to be satisfactory. Gait speed showed high sensitivity, but only moderate specificity, and excellent predictive ability for future disability in activities of daily living. The Tilburg Frailty Indicator was shown to be a reliable and valid measure for frailty screening, but its diagnostic accuracy was not evaluated. Screening Letter, Timed-up-and-go test and PRISMA 7 (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) demonstrated high sensitivity and moderate specificity for identifying frailty. In general, low physical activity, variously measured, was one of the most powerful predictors of future decline in activities of daily living. Conclusion: Only a few frailty measures seem to be demonstrably valid, reliable and diagnostically accurate, and have good predictive ability. Among them, the Frailty Index and gait speed emerged as the most useful in routine care and community settings. However, none of the included systematic reviews provided responses that met all of our research questions on their own and there is a need for studies that could fill this gap, covering all these issues within the same study. Nevertheless, it was clear that no suitable tool for assessing frailty appropriately in emergency departments was identified.

Frailty as a predictor of disabilities among community-dwelling older people: a systematic review and meta-analysis

Article

Aug 2016

Gotaro Kojima

Background: Frailty has been shown to be associated with disability in the previous studies. However, it is not clear how consistently or to how much degree frailty is actually associated with the future disability risks. Methods: A systematic review of the literature was conducted using Embase, MEDLINE, CINAHL, PsycINFO, and the Cochrane Library for any prospective studies published from 2010 to September 2015 examining associations between baseline frailty status and subsequent risk of developing or worsening disabilities among community-dwelling older people. A meta-analysis was performed to synthesize pooled estimates. Results: Of 7012 studies identified through the systematic review, 20 studies were included in the meta-analysis. Twelve studies examined activities of daily living (ADL) disability risks, two studies examined instrumental activities of daily living (IADL) disability risks, and six studies examined both ADL and IADL disability risks. Overall, frail older people were more likely to develop or worsen disabilities in ADL (12 studies, pooled OR = 2.76, 95% CI = 2.23–3.44, p < 0.00001; 5 studies, pooled HR = 2.23, 95% CI = 1.42–3.49, p < 0.00001) and IADL (6 studies, pooled OR = 3.62, 95% CI = 2.32–5.64, p < 0.00001; 2 studies, pooled HR = 4.24, 95% CI = 0.85–21.28, p = 0.08). Prefrailty was also associated with incident or worsening disability risks to a lesser degree in most pooled analyses. High heterogeneity observed among 12 studies with OR of ADL disability risks for frailty was explored using subgroup analyses, which suggested methodological quality and mean age of the cohort were the possible causes. Conclusion: This systematic review meta-analysis quantitatively showed that frail older people are at higher risks of disabilities. These results are important for all related parties given population aging worldwide. Interventions for frailty are important to prevent disability and preserve physical functions, autonomy, and quality of life. • Implications for Rehabilitation •Although frailty has been shown to be associated with disability and considered as a precursor of disability, it is not clear how consistently or to how much degree frailty is actually associated with the future disability risks. •This systematic review and meta-analysis quantitatively shows frailty is a significant predictor of incident and worsening ADL and IADL disabilities. •It is a pressing priority to develop interventions for frailty to prevent disability and preserve older people’s physical functions, autonomy, and quality of life.

Frailty as a predictor of hospitalization among community-dwelling older people: A systematic review and meta-analysis

Article

Mar 2016
J EPIDEMIOL COMMUN H

Gotaro Kojima

Background: Owing to detrimental hazards and substantial healthcare burden and costs, hospitalisation of older people has become a major focus. Frailty has increasingly been recognised as an important predictor of hospitalisation. This study aims to identify studies on physical frailty as a predictor of hospitalisation risks and to pool the risk estimates among community-dwelling older people. Methods: A systematic literature search was performed in August 2015 using five databases: EMBASE, MEDLINE, CINAHL, PsycINFO and the Cochrane Library for prospective studies examining physical frailty as a predictor of hospitalisation published in 2000 or later. OR and HR were combined to synthesise pooled effect measures using fixed-effects models. The included studies were assessed for heterogeneity, methodological quality and publication bias. Subgroup analysis and metaregression analysis were conducted to examine study characteristics in relation to the hospitalisation risks. Results Of the 4620 studies identified by the systematic review, 13 studies with average follow-up period of 3.1 years were selected. Frailty and prefrailty were significantly associated with higher hospitalisation risks among 10 studies with OR ( pooled OR=1.90, 95% CI 1.74–2.07, p<0.00001; pooled OR=1.26, 95% CI 1.18–1.33, p<0.00001, respectively) and 3 studies with HR ( pooled HR=1.30, 95% CI 1.12–1.52, p=0.0007; pooled HR=1.13, 95% CI 1.04–1.24, p=0.005, respectively). Heterogeneity was low to moderate. No publication bias was detected. The studies with older populations and unadjusted outcome measures were associated with higher hospitalisation risks in the subgroup analysis. Conclusions: This systematic review and meta-analysis demonstrated physical frailty is a significant predictor of hospitalisation among community-dwelling older people. Hospitalisation can potentially be reduced by treating or preventing frailty.

Predictive performance of four frailty measures in an older Australian population

Article

Nov 2015

Background: there are several different frailty measures available for identifying the frail elderly. However, their predictive performance in an Australian population has not been examined. Objective: to examine the predictive performance of four internationally validated frailty measures in an older Australian population. Methods: a retrospective study in the Australian Longitudinal Study of Ageing (ALSA) with 2,087 participants. Frailty was measured at baseline using frailty phenotype (FP), simplified frailty phenotype (SFP), frailty index (FI) and prognostic frailty score (PFS). Odds ratios (OR) were calculated to measure the association between frailty and outcomes at Wave 3 including mortality, hospitalisation, nursing home admission, fall and a combination of all outcomes. Predictive performance was measured by assessing sensitivity, specificity, positive and negative predictive values (PPV and NPV) and likelihood ratio (LR). Area under the curve (AUC) of dichotomised and the multilevel or continuous model of the measures was examined. Results: prevalence of frailty varied from 2% up to 49% between the measures. Frailty was significantly associated with an increased risk of any outcome, OR (95% confidence interval) for FP: 1.9 (1.4–2.8), SFP: 3.6 (1.5–8.8), FI: 3.4 (2.7–4.3) and PFS: 2.3 (1.8–2.8). PFS had high sensitivity across all outcomes (sensitivity: 55.2–77.1%). The PPV for any outcome was highest for SFP and FI (70.8 and 69.7%, respectively). Only FI had acceptable accuracy in predicting outcomes, AUC: 0.59–0.70. Conclusions: being identified as frail by any of the four measures was associated with an increased risk of outcomes; however, their predictive accuracy varied.

The Italian Version of the Tilburg Frailty Indicator: Analysis of Psychometric Properties

Article

Sep 2015
RES AGING

This study aims to assess the reliability, construct validity (convergent/divergent), and criterion validity of the Italian version of the Tilburg Frailty Indicator (TFI). The TFI is a self-report questionnaire for screening frailty in older adults. Two hundred and sixty-seven community-dwelling older adults were involved. Psychometric properties were analyzed using validated instruments. Adverse outcomes such as disability, falls, and visits to a general practitioner were detected. Participants were mainly women (59.9%), with a mean age of 73.4 years (SD = 6.0). Internal consistency reliability was acceptable. Construct validity was good, since each item of the TFI correlated as expected with corresponding frailty measures. Convergent and divergent validity were adequate for all the domains of the TFI. Criterion validity was excellent for disability and mediocre for the other two outcomes. This study supports the validity of the Italian TFI and offers to clinicians and scientists a multidimensional instrument for identifying frail individuals in the Italian context.

Frailty as a Predictor of Future Falls Among Community-Dwelling Older People: A Systematic Review and Meta-Analysis

Article

Aug 2015

Gotaro Kojima

Although multiple longitudinal studies have investigated frailty as a predictor of future falls, the results were mixed. Thus far, no systematic review or meta-analysis on this topic has been conducted. To review the evidence of frailty as a predictor of future falls among community-dwelling older people. Systematic review of literature and meta-analysis were performed using 6 electronic databases (Embase, Scopus, MEDLINE, CINAHL Plus, PsycINFO, and the Cochrane Library) searching for studies that prospectively examined risk of future fall risk according to frailty among community-dwelling older people published from 2010 to April 2015 with no language restrictions. Of 2245 studies identified through the systematic review, 11 studies incorporating 68,723 individuals were included in the meta-analysis. Among 7 studies reporting odds ratios (ORs), frailty and prefrailty were significantly associated with higher risk of future falls (pooled OR = 1.84, 95% confidence interval [95% CI] = 1.43-2.38, P < .001; pooled OR = 1.25, 95% CI = 1.01-1.53, P = .005, respectively). Among 4 studies reporting hazard ratios (HRs), whereas frailty was significantly associated with higher risk of future falls (pooled HR = 1.24, 95% CI = 1.10-1.41, P < .001), future fall risk according to prefrailty did not reach statistical significance (pooled HR = 1.14, 95% CI = 0.95-1·36, P = .15). High heterogeneity was noted among 7 studies reporting ORs and seemed attributed to difference in gender proportion of cohorts according to subgroup and meta-regression analyses. Frailty is demonstrated to be a significant predictor of future falls among community-dwelling older people despite various criteria used to define frailty. The future fall risk according to frailty seemed to be higher in men than in women. Copyright © 2015 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.

Portuguese version of the Tilburg Frailty Indicator: Transcultural adaptation and psychometric validation

Article

Jul 2015

Aim: To present the translation and validation process of the Portuguese version of the Tilburg Frailty Indicator (TFI). Methods: A cross-sectional study was designed using a non-probability sample of 252 community-dwelling older adults. Preliminary studies were carried out for face and content validity assessment. Internal consistency, test–retest reliability, construct (convergent/divergent) and criterion validity were subsequently analyzed. Results: The sample was mainly women (75.8%), with a mean age of 79.2 ± 7.3 years. TFI internal consistency was good (KR-20 = 0.78). Test–retest reliability for the total was also good (r = 0.91), with kappa coefficients showing substantial agreement for most items. TFI physical and social domains correlated as expected with concurrent measures, whereas the TFI psychological domain showed similar correlations with other psychological and physical measures. The TFI showed a good to excellent discrimination ability in regard to frailty criteria, and fair to good ability to predict adverse outcomes. Conclusions: The psychometric properties of the TFI seem to be consistently good. These findings provide initial evidence that the Portuguese version is a valid and reliable measure for assessing frailty in the elderly. Geriatr Gerontol Int 2014; ●●: ●●–●●.

Adverse outcomes of frailty in the elderly: The Rotterdam Study

Article

Jun 2014
EUR J EPIDEMIOL

To investigate the prevalence of frailty in a Dutch elderly population and to identify adverse health outcomes associated with the frailty phenotype independent of the comorbidities. Cross-sectional and longitudinal analyses within the Rotterdam Study (the Netherlands), a prospective population-based cohort study in persons aged ≥55 years. Frailty was defined as meeting three or more of five established criteria for frailty, evaluating nutritional status, physical activity, mobility, grip strength and exhaustion. Intermediate frailty was defined as meeting one or two frailty criteria. Comorbidities were objectively measured. Health outcomes were assessed by means of questionnaires, physical examinations and continuous follow-up through general practitioners and municipal health authorities for mortality. Of 2,833 participants (median age 74.0 years, inter quartile range 9) with sufficiently evaluated frailty criteria, 163 (5.8 %) participants were frail and 1,454 (51.3 %) intermediate frail. Frail elderly were more likely to be older and female, to have an impaired quality of life and to have fallen or to have been hospitalized. 108 (72.0 %) frail participants had ≥2 comorbidities, compared to 777 (54.4 %) intermediate frail and 522 (44.8 %) non-frail participants. Adjusted for age, sex and comorbidities, frail elderly had a significantly increased risk of dying within 3 years (HR 3.4; 95 % CI 1.9-6.4), compared to the non-frail elderly. This study in a general Dutch population of community-dwelling elderly able to perform the frailty tests, demonstrates that frailty is common and that frail elderly are at increased risk of death independent of comorbidities.

A Comparison of Four Frailty Models

Article

Mar 2014
J AM GERIATR SOC

Objectives To determine how well the interview-based, clinic-friendly International Academy of Nutrition and Aging (FRAIL) frailty scale predicts future disability and mortality in the African American Health (AAH) cohort compared with the clinic-friendly Study of Osteoporotic Fractures (SOF) frailty scale, the phenotype-based Cardiovascular Health Study (CHS) frailty scale, and the comprehensive Frailty Index (FI).DesignLongitudinal cohort study.SettingMetropolitan St. Louis, Missouri.ParticipantsAfrican American Health is a population-based panel study of African Americans (baseline age 49–65) from St. Louis, Missouri. Participants completed in-home assessments at baseline (N = 998) and 3- (n = 853) and 9- (n = 582) year follow-up.MeasurementsOutcomes included activity of daily living (ADL) and instrumental ADL difficulties at 3 and 9 years and 9-year mortality. Frailty measures included the FRAIL, SOF, and CHS scales and the FI.ResultsThe FRAIL, SOF, CHS, and FI measures predicted new 3- and 9-year disability, and the FRAIL and FI scales predicted 9-year mortality. Receiver operating characteristic (ROC) contrasts showed that the FRAIL scale performed as well as (9-year disability and mortality) or better than (3-year disability) the CHS and SOF scales and the FI better than the FRAIL, CHS, and SOF scales for all outcomes except the FRAIL and CHS scales for 9-year ADL difficulties. The CHS and SOF scales were equivalent for all outcomes in ROC contrasts.Conclusion Overall the FI and the FRAIL scale exhibited the strongest predictive validity for disability and mortality in AAH. The best prediction tool to identify frail individuals at risk of disability and mortality may be one that includes a comorbidity measure. The FRAIL scale includes a comorbidity item and is a brief interview-based measure that is easy to administer, score, and interpret. The FRAIL scale has demonstrated validity and may prove to be a valuable scale for use by clinicians.

Danish version of the Tilburg Frailty Indicator – Translation, Cross-cultural Adaption and Validity Pretest by Cognitive Interviewing

Article

Jul 2014

The Tilburg Frailty Indicator (TFI) is a self-administered questionnaire with a bio-psycho-social integrated approach that measures the degree of frailty in elderly persons. The TFI was developed in the Netherlands and tested in a population of elderly Dutch men and women. The aim of this study was to translate and culturally adapt the TFI to a Danish context, and to test face validity of the Danish version by cognitive interviewing. An internationally recognized procedure was applied as a basis for the translation process. The primary tasks were forward translation, reconciliation, back translation, harmonization and pretest. Pretest and review of the preliminary version by cognitive interviewing, were performed at a local community centre and in an acute medical ward at the University Hospital in Aalborg, Denmark respectively. A large agreement regarding meaning of the items in the forward translation and reconciliation process was seen. Minor discrepancies were solved by consensus. Back translation revealed unclear wording in one matter. The harmonization committee agreed on a version for cognitive interviewing after revision of minor issues and thirty-four participants were interviewed. Two issues became evident and these were revised. The cognitive interviews and final lay-out resulted in minor adjustments as text type size, specific font, and lining for optimizing readability. In conclusion, we consider the TFI to be translated in such rigorous manner that the instrument can be further tested in clinical practice. The overall objective of the questionnaire being to identify frailty and improve the interventions relating to frail elderly persons in Denmark.

Multicomponent exercises including muscle power training enhance muscle mass, power output, and functional outcomes in institutionalized frail nonagenarians

Article

Sep 2013
AGE

This randomized controlled trial examined the effects of multicomponent training on muscle power output, muscle mass, and muscle tissue attenuation; the risk of falls; and functional outcomes in frail nonagenarians. Twenty-four elderly (91.9 ± 4.1 years old) were randomized into intervention or control group. The intervention group performed a twice-weekly, 12-week multicomponent exercise program composed of muscle power training (8-10 repetitions, 40-60 % of the one-repetition maximum) combined with balance and gait retraining. Strength and power tests were performed on the upper and lower limbs. Gait velocity was assessed using the 5-m habitual gait and the time-up-and-go (TUG) tests with and without dual-task performance. Balance was assessed using the FICSIT-4 tests. The ability to rise from a chair test was assessed, and data on the incidence and risk of falls were assessed using questionnaires. Functional status was assessed before measurements with the Barthel Index. Midthigh lower extremity muscle mass and muscle fat infiltration were assessed using computed tomography. The intervention group showed significantly improved TUG with single and dual tasks, rise from a chair and balance performance (P < 0.01), and a reduced incidence of falls. In addition, the intervention group showed enhanced muscle power and strength (P < 0.01). Moreover, there were significant increases in the total and high-density muscle cross-sectional area in the intervention group. The control group significantly reduced strength and functional outcomes. Routine multicomponent exercise intervention should be prescribed to nonagenarians because overall physical outcomes are improved in this population.

Operationalization of Frailty Using Eight Commonly Used Scales and Comparison of Their Ability to Predict All-Cause Mortality

Article

Sep 2013
J AM GERIATR SOC

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 comprehensive frailty assessment instrument: Development, validity and reliability

Article

Apr 2013

Population aging forces governments to change their policy on elderly care. Older people, even if they are frail and disabled, are motivated to stay in their own homes and environment for as long as possible. Consequently, the early detection of frail older persons is appropriate to avoid adverse outcomes. Several instruments to detect frailty exist, but none use environmental indicators. This study addresses the development and psychometric properties of the Comprehensive Frailty Assessment Instrument (CFAI). This new self-reporting instrument includes physical, psychological, social and environmental domains. The CFAI showed good fit indices and a high reliability. The underlying structure of the CFAI demonstrates the multidisciplinary nature of frailty. Using the CFAI can stimulate nurses and other community healthcare providers toward a more holistic approach of frailty and can guide them to take appropriate interventions to prevent adverse outcomes such as disabilities or hospitalization.

Psychometric properties of the Brazilian version of the Tilburg frailty indicator (TFI)

Article

Mar 2013

This study aims to assess the psychometric properties of the Brazilian version of the TFI, an instrument that identifies frailty in elderly individuals. We interviewed 219 individuals aged 60 or older, living in the community. Individuals were predominantly female (52.5%) and mean age was 70.5 (±7.9) years. In order to assess test-retest reliability, 101 individuals were re-interviewed by the same observer within seven to ten days after the first interview. The internal consistency of the instrument was assessed using Cronbach's alpha. To assess construct validity, we used established alternative measures for the items that constitute the TFI, such as: body mass index (BMI), timed up and go (TUG) test, whisper test, Snellen test, upper extremity strength clinical test and mini-mental state examination (MMSE). The test-retest reliability showed high percent agreement for all the items of the instrument, with values ranging from 63% to 100%. Test-retest reliabilities were good (total TFI score r=0.88; physical domain r=0.88; psychological domain r=0.88; and social domain r=0.67). Internal consistency reliability of the Brazilian version was satisfactory (Cronbach's alpha=0.78). The correlations between TFI items and their corresponding measures were consistent except for one item (related to "ability to deal with problems"), demonstrating both convergent and divergent construct validity of the TFI and its items. After the completion of all stages of transcultural adaptation, the Brazilian version of the TFI proved to be well suited for assessing frailty in the elderly population of Brazil.

Frailty in elderly people

Article

Feb 2013
LANCET

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.

Comparison of Frailty Indicators Based on Clinical Phenotype and the Multiple Deficit Approach in Predicting Mortality and Physical Limitation

Article

Aug 2012
J AM GERIATR SOC

To compare three simple bedside tools based on frailty phenotypes with a Frailty Index using the multiple deficit approach in the prediction of mortality and physical limitation after 4 years. Cohort study. Hong Kong, China. Four thousand men and women aged 65 and older living in the community who were ambulatory enough to attend the study center. Interviewers obtained information regarding physical, psychological, and functional health; body mass index (BMI), grip strength, blood pressure, and ankle brachial index were determined. Three clinical frailty scales based on the Fried phenotype (Cardiovascular Health Study (CHS); Fatigue, Resistance, Ambulation, Illness, and Loss (FRAIL); and Hubbard) and a frailty index (FI) were constructed from these variables, and their ability to predict incident mortality and physical function limitations was compared using receiver operating characteristic (ROC) curves. All tools predicted adverse outcomes. More participants were categorized into frail and prefrail categories using the CHS than with the other two clinical scales. For all frailty measures, with increasing levels of frailty, the sensitivity fell and the specificity increased to greater than 90%; the area under the ROC curve values were approximately 0.6. Simple frailty scores are comparable with a multidimensional deficit accumulation FI in predicting mortality and physical limitations. The newer FRAIL, proposed for use in a clinical setting, is comparable with other existing short screening tools, as well as tools based on the multiple-deficits model used for research settings. Addition of a physical performance measure to screening tools may increase predictive accuracy.

Prediction of Adverse Health Outcomes in Older People Using a Frailty Index Based on Routine Primary Care Data

Article

Jul 2012
J GERONTOL A-BIOL

Background: A general frailty indicator could guide general practitioners (GPs) in directing their care efforts to the patients at highest risk. We investigated if a Frailty Index (FI) based on the routine health care data of GPs can predict the risk of adverse health outcomes in community-dwelling older people. Methods: This was a retrospective cohort study with a 2-year follow-up period among all patients in an urban primary care center aged 60 and older: 1,679 patients (987 women [59%], median age, 73 years [interquartile range, 65-81]). For each patient, a baseline FI score was computed as the number of health deficits present divided by the total number of 36 deficits on the FI. Adverse health outcomes were defined as the first registered event of an emergency department (ED) or after-hours GP visit, nursing home admission, or death. Results: In total, 508 outcome events occurred within the sample population. Kaplan-Meier survival curves were constructed according to FI tertiles. The tertiles were able to discriminate between patients with low, intermediate, and high risk for adverse health outcomes (p value < .001). With adjustments for age, consultation gap, and sex, a one deficit increase in the FI score was associated with an increased hazard for adverse health outcomes (hazard ratio, 1.166; 95% confidence interval [CI], 1.129-1.210) and a moderate predictive ability for adverse health outcomes (c-statistic, 0.702; 95% CI, 0.680-0.724). Conclusions: An FI based on International Classification of Primary Care (ICPC)-encoded routine health care data does predict the risk of adverse health outcomes in elderly population.

Measurement Properties of the Groningen Frailty Indicator in Home-Dwelling and Institutionalized Elderly People

Article

May 2012

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.

Predictive Performance of 7 Frailty Instruments for Short-term Disability, Falls and Hospitalization among Chinese Community-dwelling Older Adults: A Prospective Cohort Study

Abstract

No full-text available

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