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A global clinical measure of fitness and frailty in elderly people

  • Fraser Health Authority Simon Fraser University. Canada

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There is no single generally accepted clinical definition of frailty. Previously developed tools to assess frailty that have been shown to be predictive of death or need for entry into an institutional facility have not gained acceptance among practising clinicians. We aimed to develop a tool that would be both predictive and easy to use. We developed the 7-point Clinical Frailty Scale and applied it and other established tools that measure frailty to 2305 elderly patients who participated in the second stage of the Canadian Study of Health and Aging (CSHA). We followed this cohort prospectively; after 5 years, we determined the ability of the Clinical Frailty Scale to predict death or need for institutional care, and correlated the results with those obtained from other established tools. The CSHA Clinical Frailty Scale was highly correlated (r = 0.80) with the Frailty Index. Each 1-category increment of our scale significantly increased the medium-term risks of death (21.2% within about 70 mo, 95% confidence interval [CI] 12.5%-30.6%) and entry into an institution (23.9%, 95% CI 8.8%-41.2%) in multivariable models that adjusted for age, sex and education. Analyses of receiver operating characteristic curves showed that our Clinical Frailty Scale performed better than measures of cognition, function or comorbidity in assessing risk for death (area under the curve 0.77 for 18-month and 0.70 for 70-month mortality). Frailty is a valid and clinically important construct that is recognizable by physicians. Clinical judgments about frailty can yield useful predictive information.
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railty is a term widely used to denote a multidimen-
sional syndrome of loss of reserves (energy, physical
ability, cognition, health) that gives rise to vulnera-
bility. It appears to be a valid construct, but how exactly to
define it remains unclear.
There are many operational
which typically are rules-based; for exam-
ple, a person may be defined as frail if 3 or more symptoms
(of unintentional weight loss, feeling exhausted, weak grip
strength, slow walking speed and low physical activity) are
Rules-based definitions often are derived from
multiple regression analyses and can be speciously precise,
for example in requiring combinations of factors that might
not apply to an individual case.
Summing the number of impairments is another way to
define frailty.
Despite its strong predictive validity,
this approach is time-consuming and not widely used clin-
ically. A third class of operational classifications, which in
this report we attempt to extend, relies on clinical judg-
ment to interpret the results of history-taking and clinical
The creation of so many scales to measure frailty reflects
uncertainty about the term and its components. The ability
to measure frailty is useful at a health care policy level as
well as clinically: Information about frailty helps program
planners by identifying the range of services that might be
required and the anticipated need for them. Clinically,
frailty stratification can help to plan interventions or to
predict a patient’s risk of death or need for institutional
care. Because the scales are intended to stratify risk, the
ability to predict adverse outcomes serves a common goal.
In the Canadian Study of Health and Aging (CSHA), we
have worked with 3 approaches. First, like other groups, we
developed a rules-based definition of frailty.
Later, we de-
veloped (and still actively work with) a method of counting
a patient’s clinical deficits (identified by means of signs,
symptoms and abnormal test results). This approach is re-
producible and correlates highly with mortality,
but in
clinical use the deficit count is unwieldy. In this paper, we
describe our third approach: the derivation and validation
of the Clinical Frailty Scale, a measure of frailty based on
clinical judgment.
The CSHA is a representative 5-year prospective cohort study.
Its first stage of investigation (CSHA-1) began in 1991 with
10 263 people aged 65 years and older, recruited with the aim of
describing the epidemiology of cognitive impairment and other
important health issues in elderly Canadians.
From the clinical
examinations we did within this cohort, we developed the rules-
based frailty definition
and the Frailty Index, a measure of frailty
obtained by counting various clinical deficits (Appendix 1). After-
ward, we also developed CSHA scales for function and overall
clinical frailty, with the goal of creating tools that could stratify
elderly patients as to their relative degree of vulnerability (i.e.,
A global clinical measure of fitness and frailty
in elderly people
Kenneth Rockwood, Xiaowei Song, Chris MacKnight, Howard Bergman, David B. Hogan,
Ian McDowell, Arnold Mitnitski
Background: There is no single generally accepted clinical defini-
tion of frailty. Previously developed tools to assess frailty that
have been shown to be predictive of death or need for entry
into an institutional facility have not gained acceptance
among practising clinicians. We aimed to develop a tool that
would be both predictive and easy to use.
Methods: We developed the 7-point Clinical Frailty Scale and ap-
plied it and other established tools that measure frailty to 2305
elderly patients who participated in the second stage of the
Canadian Study of Health and Aging (CSHA). We followed
this cohort prospectively; after 5 years, we determined the
ability of the Clinical Frailty Scale to predict death or need for
institutional care, and correlated the results with those ob-
tained from other established tools.
Results: The CSHA Clinical Frailty Scale was highly correlated
= 0.80) with the Frailty Index. Each 1-category increment of
our scale significantly increased the medium-term risks of
death (21.2% within about 70 mo, 95% confidence interval
[CI] 12.5%–30.6%) and entry into an institution (23.9%, 95%
CI 8.8%–41.2%) in multivariable models that adjusted for age,
sex and education. Analyses of receiver operating character-
istic curves showed that our Clinical Frailty Scale performed
better than measures of cognition, function or comorbidity in
assessing risk for death (area under the curve 0.77 for 18-
month and 0.70 for 70-month mortality).
Interpretation: Frailty is a valid and clinically important construct
that is recognizable by physicians. Clinical judgments about
frailty can yield useful predictive information.
their risks of death and of entry into an institutional facility) with
simple clinical descriptors. We defined the Clinical Frailty Scale
using the terminology of Streiner and Norman.
Rooted in our
theoretical model of fitness and frailty
and the importance of
function (which we reported in earlier investigations),
our Clini-
cal Frailty Scale (Box 1) ranges from 1 (robust health) to 7 (com-
plete functional dependence on others).
In 1996, we began CSHA-2, the second stage of the study. Of
the 10 263 people in CSHA-1 who had been examined clinically
and found to be without dementia, 2305 (22.5%) were examined
again by one of a team of clinicians (33 family physicians, 30 in-
ternists or geriatricians, 11 neurologists and 3 psychiatrists), who
then applied the Clinical Frailty Scale and the other measures in
Box 2, for comparison. This reduced study population (874 men
[37.9%] and 1431 women) consisted of 210 people (9.1%) who
had entered institutional facilities since CSHA-1; 1326 (57.5%)
who were still living at home or elsewhere in the community and
whose 3MS screening results in CSHA-2 now indicated cognitive
impairment (i.e., a 3MS score of 77 or less); and 769 (33.4%), also
living within the community, whose 3MS scores remained at 78
or greater and who formed a comparison group.
Our objective in the present study (CSHA-3), begun in 2001,
was to validate the Clinical Frailty Scale by following those pa-
tients who remained alive 5 years after CSHA-2 (1299/2305
[56.4%]). Follow-up vital and domicile status (living in the com-
munity or in an institution) was known for all 2305 participants
who did not have dementia at the time of CSHA-2, of whom 249
had entered an institutional facility between CSHA-2 and -3.
At the end of the clinical interview in CSHA-2, the interview-
ing physician assigned the subject a score of 1 to 7 on the Clinical
Frailty Scale. Each interview was reviewed and scored again by a
multidisciplinary team that included the physician and therefore
was not blinded to the initial score.
Given the increased likelihood of falls, episodes of delirium
and cognitive impairment among people who are frail, we
recorded that information. Physicians making the initial Clinical
Frailty Scale assessment had access to diagnoses and assessments
related to these variables and other measures of comorbidity,
function and associated features that inform clinical judgments
about the severity of frailty. They were, however, unaware of sub-
jects’ results on other frailty indexes. The subjects assessed were
almost always new to the clinician involved.
To assess the construct validity of the CSHA Clinical Frailty
Scale, in the analysis we compared patients’ scores from the initial
assessments only with their results from other established tools
that indicate the degree of frailty by measuring function and co-
(see Box 2).
When applying the CSHA Function
Scale, we excluded “walking” and “transferring” because data
from nursing homes were incomplete for many patients.
The Frailty Index is a count of 70 clinical deficits from the
CSHA clinical assessment (Appendix 1). Items included the pres-
ence and severity of current diseases, ability in the activities of
daily living, and physical and neurological signs from the clinical
examinations. Each deficit was dichotomized or trichotomized
and mapped to the interval 01 (i.e., individual assessment items
could be scored as 0, 0.33, 0.50, 0.67 or 1.0) to represent the
severity or frequency of the problem (see Box 2). No variable had
more than 5% missing data. Except for the Clinical Frailty Scale
(which was completed on all but 8 patients), any values that were
missing were imputed using the relevant mean.
We used Pearson or Spearman correlation coefficients to mea-
sure the degree of correlation (i.e., to test convergent construct
validity) between the Clinical Frailty Scale and the other, estab-
lished measurement tools. To assess predictive validity, an aspect
of criterion validation,
we constructed Kaplan–Meier curves per
Rockwood et al
490 JAMC • 30 AOÛT 2005; 173 (5)490 JAMC • 30 AOÛT 2005; 173 (5)
Box 1: The CSHA Clinical Frailty Scale
Very fit
robust, active, energetic, well motivated and
fit; these people commonly exercise regularly and are in
the most fit group for their age
without active disease, but less fit than people in
category 1
Well, with treated comorbid disease
disease symptoms
are well controlled compared with those in category 4
Apparently vulnerable
although not frankly dependent,
these people commonly complain of being slowed up
or have disease symptoms
Mildly frail
with limited dependence on others for
instrumental activities of daily living
Moderately frail
help is needed with both instrumental
and non-instrumental activities of daily living
Severely frail
completely dependent on others for the
activities of daily living, or terminally ill
Note: CSHA = Canadian Study of Health and Aging.
Box 2: Tools for measuring degree of frailty that were
compared with the CSHA Clinical Frailty Scale*
Modified Mini-Mental State Examination
(3MS), in which
a score of 77 or less indicates cognitive impairment
Cumulative Illness Rating Scale,
a comorbidity measure that
has been validated with autopsies
A history of falls, delirium, cognitive impairment or dementia
(as per DSM-III-R criteria for the diagnosis of dementia)
CSHA rules-based definition of frailty,
which categorizes
subjects as 0 (having no cognitive or functional impairment),
1 (isolated urinary incontinence), 2 (dependent in 1 ADL or
having a diagnosis of CIND) or 3 (dependent in at least 2 ADLs,
having mobility impairment or having a diagnosis of dementia)
CSHA Frailty Index, a count of 70 deficits (listed in Appendix 1),
including the presence and severity of current diseases, ability
in ADLs and physical signs from clinical and neurologic exams.
(A person with 7 deficits, for example, would have an index
score of 7/70 = 0.10. The relative frailty or fitness of a patient
can be calculated as a percentage difference from the average
score for people of that age.) To indicate severity, each deficit
not restricted by its nature to two values (i.e., 0 or 1 for absence
or presence, respectively) was assigned three (0, 0.5 or 1) or four
values (0, 0.33, 0.67 or 1.0), as appropriate
CSHA Function Scale (based on the extensively validated Older
American Resources Survey), which scores the patient on each
of 12 ADLs (some instrumental) as 0 (the patient is independent
in carrying out this ADL), 1 (needs assistance) or 2 (is incapable)
Note: CSHA = Canadian Study of Health and Aging, 3MS = Modified Mini-Mental State
Examination, ADL = activity of daily living, CIND = cognitive impairment, no dementia.
*Except for the 3MS, a higher score on these tests represents greater morbidity.
The clinicians assessing study participants on the CHSA Clinical Frailty Scale were
aware of these factors in the medical history but blinded to scores from all the other
indexes listed, except for results from the 3MS (as indicated).
scale category. All significance tests were 2-sided; differences were
assessed for significance (p 0.05) with the log–rank test. In the
multivariable analyses, having first checked for proportionality,
we used Cox regression analyses to estimate hazard ratios and
construct 95% confidence intervals (CIs) independently for the
3MS score
and outcomes of the CSHA Clinical Frailty Scale,
and the Cumulative Illness Rating Scale,
as well as the CSHA’s
Function Scale, rules-based frailty definition
and Frailty Index,
adjusting each for age, sex and years of education. Receiver oper-
ating characteristic (ROC) curves
were calculated to estimate the
areas under the curves for relevant predictor variables in relation
to death and entrance into an institutional facility. An intraclass
correlation coefficient was used to assess interrater reliability be-
tween the 2 Clinical Frailty Scale ratings (i.e., the initial scorings
done by physicians and those done later by multidisciplinary
teams during CSHA-2).
The research ethics committees of each institution approved
the study, and all participants (or their designates) signed
informed-consent forms. CSHA funding was chiefly (> 95%) pub-
lic and from a variety of sources, as specified in the Acknowledge-
ments. Sponsors had no role in the selection of the objectives or
in the analysis, write-up or submission of this report.
Participants with higher scores on the Clinical Frailty
Scale were older and more likely to be female, cognitively
impaired and incontinent; to have impaired mobility and
function: and to have more comorbid illnesses than those
with lower scores (Table 1). They also had higher scores
according to both the Frailty Index and the rules-based
frailty definition.
Of note, at the highest level of frailty
our participants had fewer falls, probably reflecting the
greater proportion who were bedridden. The degree of
correlation between the judgment-based CSHA Clinical
Frailty Scale and the mathematically derived Frailty Index
was high (Pearson coefficient 0.80, p < 0.01), confirming
construct validity. The Clinical Frailty Scale and the Frailty
Fitness and frailty in elderly people
CMAJ AUG. 30, 2005; 173 (5) 491
Table 1: Distribution of frailty attributes by category of the Canadian Study of Health and Aging (CSHA) Clinical Frailty Scale*
12 3 4567
Well, with treated
comorbid disease
Patients, no. 216 260 476 349 305 497 194
Age, mean (SD), yr 80.3 (5.9) 83.0 (6.8) 82.4 (6.3) 83.7 (6.2) 86.4 (6.5) 87.4 (6.7) 88.1 (7.1)
Education, mean (SD), grade 9.6 (4.1) 9.9 (4.2) 9.6 (4.1) 8.8 (3.7) 9.7 (4.1) 9.4 (3.9) 9.1 (3.9)
Women, % 51.8 58.5 57.1 56.2 64.6 68.6 80.4
No cognitive impairment, % 75.9 63.1 57.1 39.3 18.7 9.7 1.0
Cognitive impairment, no
dementia, % 20.4 29.2 34.9 45.6 39.7 21.5 5.8
Dementia, % 3.7 7.7 8.0 15.2 41.6 68.8 93.3
With falls, % 13.0 20.8 24.6 40.4 45.9 48.7 31.4
With urinary incontinence, % 8.3 12.3 17.2 26.6 31.8 60.4 92.8
With impaired mobility, % 0.5 0.8 5.2 18.3 37.7 57.9 63.4
Modified Mini-Mental State
Examination, mean score* (SD)
87.1 (9.9) 82.6 (13.9) 83.2 (12.7) 79.1 (13.3) 70.2 (17.7) 56.2 (22.2) 31.9 (21.0)
Cumulative Illness Rating Scale,
mean score (SD) 1.8 (1.9) 2.5 (2.3) 4.9 (2.8) 6.2 (3.1) 6.4 (3.9) 7.0 (4.0) 6.4 (4.7)
CSHA measurement tools
Rules-based frailty definition,
mean score (SD) 0.72 (1.01) 1.14 (1.08) 1.34 (1.08) 1.90 (0.95) 2.45 (0.71) 2.82 (0.40) 2.94 (0.23)
Frailty Index, mean score (SD) 0.09 (0.05) 0.12 (0.05) 0.16 (0.07) 0.22 (0.08) 0.27 (0.09) 0.36 (0.09) 0.43 (0.08)
Function Scale, mean score (SD) 0.05 (0.12) 0.11 (0.16) 0.15 (0.19) 0.27 (0.22) 0.45 (0.24) 0.71 (0.24) 0.87 (0.19)
*Except for Modified Mini-Mental State Examination results, higher scores indicate worse function.
Table 2: Cox proportional hazard ratios (HR) for time until
death and until the requirement for institutional care
HR (95% CI)
Entry into institution,
HR (95% CI)
Age 1.08 (1.071.08) 1.15 (1.101.13)
Sex 0.83 (0.780.89) 1.38 (1.211.58)
Education level* 0.98 (0.970.99) 0.98 (0.970.99)
Modified Mini-Mental
State Examination 0.84 (0.820.86) 0.65 (0.600.70)
Cumulative Illness
Rating Scale 1.14 (1.111.17) 1.22 (1.161.27)
CSHA measuring tools
Rules-based definition
of frailty
1.17 (1.131.20) 1.27 (1.191.35)
Frailty Index 1.26 (1.241.29) 1.56 (1.481.65)
Function Scale 1.16 (1.131.20) 1.29 (1.201.39)
Clinical Frailty Scale 1.30 (1.271.33) 1.46 (1.391.53)
Note: CI = confidence interval, CSHA = Canadian Study of Health and Aging.
All scales were adjusted for age, sex and number of years of education, and recategorized into
7-level scales to compare with the Clinical Frailty Scale.
*Univariate estimate.
Index each correlated to a similar degree with age (0.35 and
0.29, respectively); the 3MS measure of cognition (0.58,
0.59); the Cumulative Illness Rating Scale, which measures
comorbidity (0.43, 0.48); the CSHA Function Score (0.78,
0.74); and the CSHA rules-based frailty definition (0.67
and 0.65, respectively). Reliability between the 2 ratings of
the CSHA Clinical Frailty Scale assessments was very high
(intraclass correlation coefficient 0.97, p < 0.001).
Hazard ratios for death and entry into an institutional
facility (Table 2) in each case showed increasing risk with
increasing frailty (Fig. 1, upper graph). ROC curve analyses
of the CSHA Clinical Frailty Scale and the Frailty Index
revealed similar areas under the curves, a performance bet-
ter than that of the other measures (Table 3). The best
result was achieved for near-term mortality (death within
18 months), with an area under the curve of 0.77.
Similarly, worse frailty was associated with an increased
probability of entering an institutional facility (Fig. 1,
lower graph). The Clinical Frailty Scale and the Frailty In-
dex had comparable performances in ROC analyses, which
again was better than the performance of the 3MS or
Cumulative Illness Rating Scale tools (Table 3). However,
the CSHA Function Scale showed sig-
nificantly better performance than all
other measures in assessing risk for en-
try into an institution.
In multivariable models that adjusted
for age, sex and education (Fig. 1), each
1-category increment of our Clinical
Frailty Scale significantly increased the
medium-term risks (i.e., those within
about 70 months) of death (21.2%,
95% CI 12.5%–30.6%) and entry into
institutional care (23.9%, 95% CI 8.8%–
We have shown that the Clinical
Frailty Scale is an effective measure of
frailty and provides predictive informa-
tion similar to that of other established
tools about death or the need for an
institution. The Clinical Frailty Scale is
easy to use and may readily be adminis-
tered in a clinical setting, an advantage
over the tools previously developed. For
example, counting deficits with the
Frailty Index is easy to understand, and
powerfully correlates the relation be-
tween frailty and death; on the other
hand, it requires the physician to consi-
der a list of no fewer than 70 possible
disorders. The 7-category Clinical Frail-
ty Scale showed good criterion validity,
with a dose–response effect in relation to
5-year prediction of death or entry into
an institutional facility and reasonable
construct validity, with worse health
characteristics associated with increasing
The Clinical Frailty Scale mixes
items such as comorbidity, cognitive im-
pairment and disability that some other
groups separate in focusing on physical
Although support exists for sepa-
rate approaches,
consensus does not,
Rockwood et al
492 JAMC 30 AOÛT 2005; 173 (5)
Time, mo
Probability of survival
Time, mo
Probability of avoidance
of institutional care
Score (
1–3 (
4 (
5 (
6–7 (
Fig. 1: Kaplan–Meier curves, adjusted for age and sex, for study participants (
over the medium term (5–6 years), according to their scores on the CSHA Clinical
Frailty Scale. Some scores were grouped. Top: Probability of survival. Bottom:
Probability of avoidance of institutional care.
and there are reasons to be skeptical. The physical frailty
approach rests on unspecified assumptions about an un-
quantitated “physiological reserve”; its predictive validity is
no better than a more comprehensive account. Empirically,
most elderly patients who are physically frail show some
level of disability, although this aspect of the debate de-
pends on the definitions employed
and in any case
would be captured by our designation of being “apparently
Applying the Clinical Frailty Scale to patients requires
judgment. The fabric of individual health has many strands,
and it seems likely that some clinicians sometimes used fac-
tors not precisely specified in our brief set of descriptors.
Some readers might be inclined to view such subjectivity
poorly, but we do not see flexibility as a weakness: Differ-
ent clinicians will emphasize different aspects of illness dif-
ferently — as in, for example, a psychiatrist and a neurol-
ogist each validly concluding, by distinct processes, that a
given patient has frontotemporal dementia. Such flexibility
is widely validated in similar settings.
It also appears to
us to be analogous to the advanced computing techniques
that we have used in recent inquiries to enhance the per-
formance of the high-dimension Frailty Index.
instance, an artificial neural network can be used to calcu-
late weighted scores, and can significantly improve the
Frailty Index’s predictive performance over an unweighted
What an artificial neural network cannot do, however, is
describe which factors most increase risk. This appears to
us to be analogous to clinical judgments about the same
phenomenon. Both clinical judgment and such advanced
computational techniques can be contrasted with a rules-
based frailty approach, which specifies combinations
a priori but at the expense of not including the patients that
most clinicians would recognize as frail.
The present inquiry showed that the predictive validity
of the CSHA’s Frailty Index and Clinical Frailty Scale were
indistinguishable; moreover, both measures performed bet-
ter in this regard than did the rules-based frailty definition.
On these grounds, and given that rules-based combinations
cannot fully embrace the complexity of states in which indi-
vidual people can find themselves, a judgment-based system
seems to be a reasonable way to measure relative fitness and
frailty. For such an instrument to be used routinely, how-
ever, more information is needed about its interrater relia-
bility, which is the subject of additional studies. Until those
study results become available, the Clinical Frailty Scale
can be used to provide broad guidelines for helping to ad-
vise about the best mix of care for elderly patients.
Our data must be interpreted with caution. Although
CSHA was population-based, CSHA-2 clinical examin-
ations overrepresent people with cognitive impairment and
those in institutions. This probably accounts for the Clinical
Frailty Scale’s bimodal distribution, with peaks at 3 (“well,
with treated comorbid disease”) and at 6 (“moderately
frail”). On the other hand, the Clinical Frailty Scale showed
a wider distribution than might be expected with a purely
clinical sample, and our study was large enough to generate
estimates with narrow confidence intervals. The only mea-
sure of test–retest or interrater reliability available to us was
unblinded; that reliability estimate is therefore likely to be
higher than would be the case in usual practice. Category 7
appeared to mix 2 groups that seem distinct: terminally ill
people (who might still be independent) and those who are
totally dependent on others tao carry out their activities of
daily living. Although people in category 7 had a high mor-
tality, these subgroups routinely would be distinguished
clinically; future users of the scale might do well to sub-
divide these groups, especially in acute care settings.
We can envisage future roles for CSHA’s Frailty Index
and Clinical Frailty Scale alike. The judgment-based scale
might be better exploited where clinicians are available who
have experience in the care of elderly people. The index ap-
proach might better serve where such access is unavailable.
The index approach also appears to have some important
mathematical advantages in its scaling that might lead to
novel insights,
especially into matters such as physio-
logic reserve, which is often invoked in relation to frailty
but little measured. Given the increasingly elderly popula-
tion, and the particular challenge posed by elderly people
who are frail, the important questions for researchers now
are how to measure frailty more precisely and how to bet-
ter translate frailty measurement into clinically sensible
tools and practices.
Fitness and frailty in elderly people
CMAJ AUG. 30, 2005; 173 (5) 493
Table 3: Receiver operating characteristic (ROC) analyses for
adverse outcomes within 70 months
Area under the ROC curve
Assessment tool
Entry into
an institution
Cumulative Illness Rating Scale 0.58 0.62
Modified Mini-Mental State Examination 0.64 0.69
CSHA rules-based definition of frailty 0.66 0.70
CSHA Function Scale 0.68 0.80
CSHA Frailty Index 0.69 0.72
CSHA Clinical Frailty Scale 0.70 0.75
Note: CSHA = Canadian Study of Health and Aging.
This article has been peer reviewed.
From the Division of Geriatric Medicine, Dalhousie University, Halifax, NS
(Rockwood, Song, MacKnight, Mitnitski); the Division of Geriatric Medicine,
McGill University, Montréal, Que. (Bergman); the Division of Geriatric Medicine,
University of Calgary, Calgary, Alta. (Hogan); and the Department of Epidemiol-
ogy and Community Medicine, University of Ottawa, Ottawa, Ont. (McDowell)
Competing interests
: None declared.
: Kenneth Rockwood designed the study, wrote the first and final
drafts of the manuscript, and supervised the analyses. Xiaowei Song and Arnold
Mitnitski conducted and verified all the analyses. (Arnold Mitnitski and Kenneth
Rockwood previously devised and tested the Frailty Index.) Kenneth Rockwood,
Chris MacKnight, David Hogan and Howard Bergman examined patients. Ian
McDowell, Chris MacKnight and David Hogan commented on and revised interim
drafts. All authors contributed to and approved the final published version and sup-
port the presented results.
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Rockwood et al
494 JAMC 30 AOÛT 2005; 173 (5)
Correspondence to: Dr. Kenneth Rockwood, Centre for Health
Care of the Elderly, 14215955 Veterans Memorial Lane,
Halifax NS B3H 2E1; fax 902 473-1050;
: This analysis was supported by grants from the National
Health Research Development Program of Health Canada (grant no. 6603-1417-55)
and the Queen Elizabeth II Research Foundation. The data reported in this article
were collected as part of the Canadian Study of Health and Aging. The core study
was funded by the Seniors’ Independence Research Program, through the National
Health Research and Development Program, project no. 6606-3954-MC(S). Addi-
tional funding was provided by Pfizer Canada Incorporated through the Medical
Research Council/Pharmaceutical Manufacturers Association of Canada Health
Activity Program, the National Health Research and Development Program, pro-
ject no. 6603-1417-302(R). The study was coordinated through the University of
Ottawa and Health Canada’s Division of Aging and Seniors. Additional funds for
analysis came from the Canadian Institutes for Health Research (CIHR) grant
MOP 62823 and the Dalhousie University Internal Medicine Research Foundation.
Kenneth Rockwood and Chris MacKnight receive CIHR support through Investi-
gator and New Investigator awards, respectively. Kenneth Rockwood is also sup-
ported by the Dalhousie Medical Research Foundation as Kathryn Allen Weldon
Professor of Alzheimer Research. Howard Bergman is Dr. Joseph Kaufman Pro-
fessor of Geriatric Medicine at McGill University, and David Hogan is Brenda
Strafford Foundation Chair in Geriatric Medicine at the University of Calgary.
Fitness and frailty in elderly people
CMAJ AUG. 30, 2005; 173 (5) 495
Appendix 1: List of variables used by the Canadian Study of Health and Aging to construct the 70-item CSHA Frailty Index
Changes in everyday activities
Head and neck problems
Poor muscle tone in neck
Bradykinesia, facial
Problems getting dressed
Problems with bathing
Problems carrying out personal grooming
Urinary incontinence
Toileting problems
Bulk difficulties
Rectal problems
Gastrointestinal problems
Problems cooking
Sucking problems
Problems going out alone
Impaired mobility
Musculoskeletal problems
Bradykinesia of the limbs
Poor muscle tone in limbs
Poor limb coordination
Poor coordination, trunk
Poor standing posture
Irregular gait pattern
Mood problems
Feeling sad, blue, depressed
History of depressed mood
Tiredness all the time
Depression (clinical impression)
Sleep changes
Memory changes
Short-term memory impairment
Long-term memory impairment
Changes in general mental functioning
Onset of cognitive symptoms
Clouding or delirium
Paranoid features
History relevant to cognitive impairment
or loss
Family history relevant to cognitive
impairment or loss
Impaired vibration
Tremor at rest
Postural tremor
Intention tremor
History of Parkinsons disease
Family history of degenerative disease
Seizures, partial complex
Seizures, generalized
Syncope or blackouts
Cerebrovascular problems
History of stroke
History of diabetes mellitus
Arterial hypertension
Peripheral pulses
Cardiac problems
Myocardial infarction
Congestive heart failure
Lung problems
Respiratory problems
History of thyroid disease
Thyroid problems
Skin problems
Malignant disease
Breast problems
Abdominal problems
Presence of snout reflex
Presence of the palmomental reflex
Other medical history
Clinical trial registration
will consider clinical trials for publication only if they
have been registered in a publicly accessible clinical trials reg-
istry before the enrolment of the first patient. This policy applies
to trials that start recruiting on or after July 1, 2005. For trials
that began enrolment before this date, registration is required
by Sept. 13, 2005. The criteria for acceptable registration are
described in
... 11 The CFS was first developed as an alternative to both frailty paradigms as a simple score to summarise a geriatrician's comprehensive assessment. 12 It has become a popular tool because of its accessibility in an acute presentation. It does not require additional records, investigations, or equipment, none of which might be available in an emergency situation, when working across networks of care, or in settings where connectivity is restricted, such as in low-income and middle-income countries. ...
... Patients who had preinjury frailty had increased odds of inpatient complications (n=16 504; appendix pp 7-8). We found no significant association between frailty and day-30 readmission (n=16 092; appendix pp 9-10) nor with duration of stay in critical care (n=2101; appendix pp [11][12]. ...
... Frailty The Clinical Frailty Scale will be used to summarise the overall level of fitness or frailty of an older adult [46]. The scale is a way to summarise information from a clinical encounter with an older person, which is useful to screen for and quantify an individual's overall health status [46]. ...
... Frailty The Clinical Frailty Scale will be used to summarise the overall level of fitness or frailty of an older adult [46]. The scale is a way to summarise information from a clinical encounter with an older person, which is useful to screen for and quantify an individual's overall health status [46]. ...
Full-text available
Background The prevalence of low back pain increases with age and has a profound impact on physical and psychosocial health. With increasing age comes increasing comorbidity, and this also has pronounced health consequences. Whilst exercise is beneficial for a range of health conditions, trials of exercise for low back pain management often exclude older adults. It is currently unknown whether an exercise program for older adults with low back pain, tailored for the presence of comorbidities, is acceptable for participants and primary healthcare providers (PHCPs). Therefore, this mixed-methods study will assess the feasibility of an 8-week comorbidity-adapted exercise program for older people with low back pain and comorbid conditions. Methods The 3-phased feasibility study will be performed in a primary healthcare setting. PHCPs will be trained to deliver a comorbidity-adapted exercise program for older people with low back pain and comorbidities. Healthcare-seeking adults > 65 will be screened for eligibility over telephone, with a recruitment target of 24 participants. Eligible participants will attend an initial appointment ( diagnostic phase ). During this initial appointment, a research assistant will collect patient demographics, self-reported outcome measurement data, and perform a physical and functional examination to determine contraindications and restrictions to an exercise program. During the development phase , PHCPs will adapt the exercise program to the individual and provide patient education. During the intervention phase , there will be two supervised exercise sessions per week, over 8 weeks (total of 16 exercise sessions). Each exercise session will be approximately 60 min in duration. A qualitative evaluation after the last exercise program session will explore the feasibility of the exercise program for participants and PHCPs. Progression criteria will determine the suitability for a fully powered randomised controlled trial. Discussion This mixed-methods feasibility study will assess an exercise program for older adults with low back pain and comorbidities. Once assessed for feasibility, the exercise program may be tested for effectiveness in a larger, fully powered randomised controlled trial. This information will add to the sparse evidence base on appropriate options for managing back pain in older adults. Trial registration Australian and New Zealand Clinical Trials Registry registration number: ACTRN12621000379819p (06/04/2021; ). Trial sponsor Macquarie University, Department of Chiropractic, Faculty of Medicine, Health and Human Sciences, Macquarie University, NSW 2109, Australia.
... The outcome of this study is frailty, which is defined following Rockwood's Cumulative Deficit Frailty Index (FI) [25]. As suggested by Moorhouse & Rockwood, the FI allows inclusion of any health deficit providing that a minimum of 30 deficits in total are included and that each deficit is associated with adverse health outcomes; increases in prevalence with age at least into the tenth decade; has a prevalence of at least 1% in the population; and does not saturate [26]. ...
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Background: Social participation (SP) may be an effective measure for decreasing frailty risks. This study investigated whether frequency and type of SP is associated with decreased frailty risk among Chinese middle-aged and older populations. Methods: Data were derived from the China Health and Retirement Longitudinal Study (CHARLS). Frailty was assessed using the Rockwood's Cumulative Deficit Frailty Index. SP was measured according to frequency (none, occasional, weekly and daily) and type (interacting with friends [IWF]; playing mah-jong, chess, and cards or visiting community clubs [MCCC], going to community-organized dancing, fitness, qigong and so on [DFQ]; participating in community-related organizations [CRO]; voluntary or charitable work [VOC]; using the Internet [INT]). Smooth curves were used to describe the trend for frailty scores across survey waves. The fixed-effect model (N = 9,422) was applied to explore the association between the frequency/type of SP and frailty level. For baseline non-frail respondents (N = 6,073), the time-varying Cox regression model was used to calculate relative risk of frailty in different SP groups. Results: Weekly (β = - 0.006; 95%CI: [- 0.009, - 0.003]) and daily (β = - 0.009; 95% CI: [- 0.012, - 0.007]) SP is associated with lower frailty scores using the fixed-effect models. Time-varying Cox regressions present lower risks of frailty in daily SP group (HR = 0.76; 95% CI: [0.69, 0.84]). SP types that can significantly decrease frailty risk include IWF, MCCC and DFQ. Daily IWF and daily DFQ decreases frailty risk in those aged < 65 years, female and urban respondents, but not in those aged ≥ 65 years, male and rural respondents. The impact of daily MCCC is significant in all subgroups, whereas that of lower-frequent MCCC is not significant in those aged ≥ 65 years, male and rural respondents. Conclusion: This study demonstrated that enhancing participation in social activities could decrease frailty risk among middle-aged and older populations, especially communicative activities, intellectually demanding/engaging activities and community-organized physical activities. The results suggested very accurate, operable, and valuable intervening measures for promoting healthy ageing.
... Furthermore, a simple frailty index with three components has been proposed based on the predictive validity of each component and its suitability for component assessment in clinical practice (Study of Osteoporotic Fractures [SOF] index) [8]. In addition, there is a frailty scale with four questions related to the components of the CHS index and one question (number of diseases) based on the Rockwood Clinical Frailty Scale [9] (Fatigue, Resistance, Ambulation, Illness and Loss of weight [FRAIL] index) [10]. These frailty measurements are widely recognised and commonly used in both clinical and population settings [6]. ...
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Background Frailty is a common issue in the aging population. Given that frailty syndrome is little discussed in the literature on the aging voice, the current study aims to examine the relationship between frailty and vocal biomarkers in older people. Methods Participants aged ≥ 60 years visiting geriatric outpatient clinics were recruited. They underwent frailty assessment (Cardiovascular Health Study [CHS] index; Study of Osteoporotic Fractures [SOF] index; and Fatigue, Resistance, Ambulation, Illness, and Loss of weight [FRAIL] index) and were asked to pronounce a sustained vowel /a/ for approximately 1 s. Four voice parameters were assessed: average number of zero crossings (A1), variations in local peaks and valleys (A2), variations in first and second formant frequencies (A3), and spectral energy ratio (A4). Results Among 277 older adults, increased A1 was associated with a lower likelihood of frailty as defined by SOF (odds ratio [OR] 0.84, 95% confidence interval [CI] 0.74–0.96). Participants with larger A2 values were more likely to be frail, as defined by FRAIL and CHS (FRAIL: OR 1.41, 95% CI 1.12–1.79; CHS: OR 1.38, 95% CI 1.10–1.75). Sex differences were observed across the three frailty indices. In male participants, an increase in A3 by 10 points increased the odds of frailty by almost 7% (SOF: OR 1.07, 95% CI 1.02–1.12), 6% (FRAIL: OR 1.06, 95% CI 1.02–1.11), or 6% (CHS: OR 1.06, 95% CI 1.01–1.11). In female participants, an increase in A4 by 0.1 conferred a significant 2.8-fold (SOF: OR 2.81, 95% CI 1.71–4.62), 2.3-fold (FRAIL: OR 2.31, 95% CI 1.45–3.68), or 2.8-fold (CHS: OR 2.82, 95% CI 1.76–4.51, CHS) increased odds of frailty. Conclusions Vocal biomarkers, especially spectral-domain voice parameters, might have potential for estimating frailty, as a non-invasive, instantaneous, objective, and cost-effective estimation tool, and demonstrating sex differences for individualised treatment of frailty.
Full-text available
The report illustrates the state of the art of the most successful AAL applications and functions based on audio and video data, namely (i) lifelogging and self-monitoring, (ii) remote monitoring of vital signs, (iii) emotional state recognition, (iv) food intake monitoring, activity and behaviour recognition, (v) activity and personal assistance, (vi) gesture recognition, (vii) fall detection and prevention, (viii) mobility assessment and frailty recognition, and (ix) cognitive and motor rehabilitation. For these application scenarios, the report illustrates the state of play in terms of scientific advances, available products and research project. The open challenges are also highlighted.
Full-text available
Background Appropriate and acceptable recruitment strategies and assessment tools are essential to determine the health needs for people experiencing homelessness. Based on a systematic review and known feasible community-based health assessments for people who are not homeless, a set of health assessments were trialled with people experiencing homelessness. Methods Participants were recruited via support agencies. They completed a health risk assessment, demographic and self-report health questionnaires, and objective assessments across 17 domains of health. Results Fifty-three participants (43.3% female, mean age 49.1 years) consented and completed 83–96% of assessments. Consent was reversed for assessments of grip, foot sensation, body measures (11%), and walking (30%), and initially refused for stress, sleep, cognition (6%); balance, walk test (9%) and oral examination (11%). There was one adverse event. Most assessments were both appropriate and acceptable. Some required modification for the context of homelessness, in particular the K10 was over-familiar to participants resulting in memorised responses. Recruitment strategies and practices must increase trust and ensure participants feel safe. Conclusions This set of health assessments are appropriate and acceptable for administration with people experiencing homelessness. Outcomes of these assessments are essential to inform public and primary health service priorities to improve the health of people experiencing homelessness.
Advanced lung cancer is a deadly malignancy that is a common cause of death among Veterans. Significant advancements in lung cancer therapeutics have been made over the past decade and survival outcomes have improved. The Veteran population is older, has more medical comorbidities and frailty compared to the general population. These factors must be accounted for when evaluating patients for treatment and selecting treatment options. This article explores the impact of these important issues in the management of advanced lung cancer. Recent clinical trials leading to the approval of modern therapies will be outlined and treatment outcomes specific to older patients discussed. The impact of key comorbidities that are common in Veterans and their impact on lung cancer treatment will be reviewed. There is no gold standard frailty index for assessment of frailty in patients with advanced lung cancer and the ability to predict tolerability and benefit from systemic therapies. Currently available systemic therapies are associated with higher risk of adverse events and lower potential for clinically meaningful improvement in outcomes. Future research needs to focus on designing better frailty indices and developing novel therapies that are safer and more effective therapies for frail patients, who constitute a considerable proportion of individuals diagnosed with lung cancer.
Background A postural blood pressure assessment is required to diagnose Orthostatic Hypotension. With increasing remote consultations, alternative methods of performing postural blood pressure assessment are required. Objective Determine whether postural blood pressure measurement at home, without a clinician, is reliable, feasible and safe. Design Service improvement project within a falls and syncope service in Northeast England. Subjects Eligibility criteria: aged ≥60 years; postural blood pressure measurement is indicated and is physically and cognitively able to perform. Exclusion criteria: nursing home residents, attending clinic in person. Methods Postural blood pressure measurements were performed in patients’ homes under clinical observation. Patient-led assessments were performed independent of the clinician, following written guidance. This was followed by a clinical-led assessment after 10-minute supine rest. Outcomes Agreement between patient and clinician derived postural blood pressure values and diagnosis of Orthostatic Hypotension; intervention safety, feasibility and acceptability. Results Twenty-eight patients were eligible and 25 participated (mean age 75, median Clinical Frailty Score five). There was 95% agreement (Cohen’s kappa 0.90 (0.70, 1.00)) between patient and clinician derived readings to diagnose orthostatic hypotension. Postural systolic blood pressure drop correlated strongly (r = 0.80), with patient derived readings overestimating by 1 (−6, 3) mmHg. Limits of agreement, determined via Bland Altman analysis, were +17 and −20 mmHg, greater than pre-determined maximum clinically important difference (±5 mmHg). Twenty participants performed valid postural blood pressure assessments without clinical assistance. Conclusions Patient-led postural blood pressure assessment at home is a reliable, safe and acceptable method for diagnosing Orthostatic Hypotension.
Background Few studies have explored the utility of screening for cognitive impairment near hospital discharge in intensive care unit survivors. Objectives To explore baseline and hospitalization characteristics associated with cognitive impairment at hospital discharge and the relationship between cognitive impairment and 6-month disability and mortality outcomes. Methods Hospital disability status and treatment variables were collected from 2 observational cohort studies. Patients were screened for cognitive impairment at hospital discharge using the Montreal Cognitive Assessment (MoCA)–Blind, and telephone follow-up was conducted 6 months after discharge to assess vital and physical disability status. Results Of 423 patients enrolled, 320 were alive at hospital discharge. A total of 213 patients (66.6%) were able to complete the MoCA near discharge; 47 patients (14.7%) could not complete it owing to cognitive impairment. In MoCA completers, the median (IQR) score was 17 (14-19). Older age (β per year increase, −0.09 [95% CI, −0.13 to −0.05]) and blood transfusions during hospitalization (β, −1.20 [95% CI, −2.26 to −0.14]) were associated with lower MoCA scores. At 6-month follow-up, 176 of 213 patients (82.6%) were alive, of whom 41 (23.3%) had new severe physical disabilities. Discharge MoCA score was not significantly associated with 6-month mortality (adjusted odds ratio, 1.03 [95% CI, 0.93-1.14]) but was significantly associated with risk of new severe disability at 6 months (adjusted odds ratio, 0.85 [95% CI, 0.76-0.94]). Conclusion Assessing for cognitive impairment at hospital discharge may help identify intensive care unit survivors at higher risk of severe physical disabilities after critical illness.
Background: The frailty was associated with the worse surgical outcomes and poor prognosis in several cancers. Therefore, we aimed to identify the usefulness of nutrition and exercise intervention (NEI) in frailty patients with GC. Methods: We analyzed 58 frailty patients with GC who underwent radical surgery. Among these, 15 patients were performed NEI by nutritional and rehabilitation support team. We compared the surgical outcomes between NEI and non-NEI groups with frailty patients and evaluated the nutrition and rehabilitation markers in pre- and post-NEI groups. Results: The postoperative complication of NEI groups was 6.7% and less than that of non-NEI groups (p = 0.08). The mean postoperative hospital stay of NEI groups was 13.0 ± 1.0 days for NEI groups and significantly shorter than that of non-NEI groups (p = 0.03). The NLR was 4.3 ± 0.6 for pre-NEI and significantly improved by NEI between pre- and post-NEI (p = 0.03). Conclusion: We identified the clinical importance of NEI for improving the surgical outcomes in frailty patients with GC. Our findings highlight the potential clinical impact of optimizing treatment strategies to select and manage the frailty patients.
Full-text available
The first wave of the Canadian Study of Health and Aging (CSHA) constituted a large health survey of a representative sample of elderly Canadians. Other Canadian surveys from the same era provided equivalent figures, and the present report compares the results of 6 surveys on a variety of health indicators. Agreement was close on self-reported chronic health conditions, adequate for several indicators of functional limitation, but was lower for overall self-ratings of the impact of health problems on day-to-day life. Using the CSHA data to compare alternative operational definitions of frailty, a definition based on ADL limitations appeared to offer an underestimate; addition of IADL questions or cognitive limitations provided figures that appeared more plausible. Survey estimates of chronic health conditions appear consistent, as are estimates of certain ADL disabilities. Care must be taken with interpreting more subjective reports, while prevalence of frailty varies considerably according to the definition used.
Objective: To estimate the incidence of dementia, including AD, among Canadians aged 65 and over. Methods: A 5-year cohort study of 10,263 seniors was undertaken, including community and institutional samples. The baseline study in 1991 identified 1,132 prevalent cases of dementia through screening and clinical examination. The remaining 9,131 cases formed the incidence study sample and were rescreened and selectively reexamined in 1996. Incident cases were diagnosed using established criteria. Incidence was estimated based on the 1991 population, and included data on those who died between the first and second phases of the study. Results: Of the nondemented cohort who remained alive in 1996, 5,432 people in the community (88.3%) and 210 (91.3%) in the institutional sample participated in the incidence study. Nine hundred sixty incident cases were identified; the overall age-standardized incidence rates were 21.8 (women) and 19.1 (men) per 1,000 nondemented persons per year. This translates into 60,150 new cases of dementia per year in Canada. The logarithm of the rates rises linearly with age, but suggests a slight slowing of growth in incidence in the oldest age groups. Conclusions: Our incidence estimates lie toward the upper end of the range of incidence estimates found in other studies. Nonetheless, we calculate that several factors may have biased our estimates downward, suggesting that the incidence of dementia may be higher than many studies have reported.
Frailty is a term that is used often, but commonly not defined precisely. As reviewed elsewhere most definitions share several features. Typically, older adults who are frail have a greater rate of dependence on others, so-called ‘loss of physiological reserve’ and multiple diseases. A dynamic component is often included (e.g. ‘loss of reserve’ and such synonyms as ‘unstable disability’ and ‘impaired homeostenosis’) and is manifest when, over time, patients respond less well to stress, or when those with given levels of frailty have higher rates of adverse outcomes. Still, the imprecision of the term frailty has led some to question its merit, and either to develop alternative means of classification or to stay with the concept of function and disability. Alternative methods of classification are either broadly or narrowly focussed.
The limitations of diagnostic "accuracy" as a measure of decision performance require introduction of the concepts of the "sensitivity" and "specificity" of a diagnostic test. These measures and the related indices, "true positive fraction" and "false positive fraction," are more meaningful than "accuracy," yet do not provide a unique description of diagnostic performance because they depend on the arbitrary selection of a decision threshold. The receiver operating characteristic (ROC) curve is shown to be a simple yet complete empirical description of this decision threshold effect, indicating all possible combinations of the relative frequencies of the various kinds of correct and incorrect decisions. Practical experimental techniques for measuring ROC curves are described, and the issues of case selection and curve-fitting are discussed briefly. Possible generalizations of conventional ROC analysis to account for decision performance in complex diagnostic tasks are indicated. ROC analysis is shown to be related in a direct and natural way to cost/benefit analysis of diagnostic decision making. The concepts of "average diagnostic cost" and "average net benefit" are developed and used to identify the optimal compromise among various kinds of diagnostic error. Finally, the way in which ROC analysis can be employed to optimize diagnostic strategies is suggested.
Accurate classification of clinical severity is important for interpreting casemix in clinical studies and for stratifying patients for clinical trials. To evaluate whether clinical judgment might be an effective method of estimating severity, all 604 patients admitted to the medical service in a one month period were rated at the time of admission by the responsible resident as to how sick they were. Within the 13 comorbid disease groups, and within the 15 basic categories of reason for admission, the physicians' severity ratings were the most significant predictor of in-hospital mortality. Death rates rose from 0% in those rated as not ill, to 2% in the mildly ill, to 6% in the moderately ill, to 23% in the severely ill, and to 58% in those rated as moribund (p less than 0.001). Sickness ratings also predicted time to death: mildly ill patients died after prolonged hospitalizations, while the moribund died shortly after admission. The patients' age, sex, race, the number of comorbid diseases or problems did not predict mortality. Patients with serious comorbidity (metastases, AIDS, or cirrhosis) had a higher mortality rate than other patients (p less than 0.001); however, the severity ratings predicted outcomes within this group (p less than 0.001) as well as among those without such serious comorbidity (p less than 0.001). Patients who were admitted with acute neurologic (p less than 0.05) or acute cardiovascular (p less than 0.01) events did have an independently worse prognosis. In conclusion, physicians' estimates or sickness provided an accurate estimate of illness severity, with mortality rates that essentially tripled from one stratum to the next. Clinical judgment may suffice to classify the clinical severity of patients at the time of enrollment in prospective trials and can provide a useful method of controlling for casemix.
The Mini-Mental State (MMS) examination is a widely used screening test for dementia. The Modified Mini-Mental State (3MS) incorporates four added test items, more graded scoring, and some other minor changes. These modifications are designed to sample a broader variety of cognitive functions, cover a wider range of difficulty levels, and enhance the reliability and the validity of the scores. The 3MS retains the brevity, ease of administration, and objective scoring of the MMS but broadens the range of scores from 0-30 to 0-100. Greater sensitivities of the 3MS over the MMS are demonstrated with the pentagon item drawn by 249 patients. A summary form for administration and scoring that can generate both the MMS and the 3MS scores is provided so that the examiner can maintain continuity with existing data and can obtain a more informative assessment.
To describe a population that was categorized as "cognitively impaired not demented" (CIND) and to examine the utility of some of the proposed criteria for describing this degree of cognitive impairment. Population-based prevalence study of dementia in those subjects who were 65 years and older. Community and institutional settings in Canada. Individuals who underwent a clinical evaluation (N = 2914). Initial screening with the Modified Mini-Mental State Examination (3MS) to identify potential cognitive impairment; the 3MS was followed by a detailed clinical examination to confirm the presence of dementia and to determine the probable cause. Clinical examinations were performed on all those subjects who were residing in institutions, those in the community with a 3MS score less than 78, and a sample of those in the community with a 3MS score of 78 or more. Neuropsychological testing was performed as part of the clinical examination when the 3MS score was 50 or more. At the conclusion of the assessment, subjects were categorized as being cognitively normal, CIND, and demented. Frequency of a diagnosis of CIND; demographical, cognitive, and functional characteristics of cognitively normal and CIND subjects and those with early and late dementia; and proportion of subjects who were CIND and met the proposed criteria. Subjects who were categorized as CIND were common and fell between cognitively normal subjects and those with dementia in terms of age, 3MS score, general intellectual function, and performance of daily activities. Because of the restrictive inclusion and exclusion criteria, the proposed criteria for cognitive impairment described only 30% of our subjects who were CIND. Subjects who were categorized as CIND appeared to be distinct from and intermediate between subjects with dementia and cognitively normal subjects. Most individuals did not meet the criteria that were evaluated for describing this group. While the various criteria that were evaluated may accurately define a select subset of cognitively impaired individuals, the natural history and prognosis of such groups, currently unknown, may not be generalizable to the larger population of subjects who are CIND. Further work is needed to clearly define this group, and longitudinal studies are required to determine an outcome.