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A global clinical measure of fitness and frailty in elderly people

Authors:
  • Fraser Health Authority Simon Fraser University. Canada

Abstract and Figures

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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CMAJ • AUG. 30, 2005; 173 (5) 489
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Research
Recherche
F
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.
1–8
There are many operational
definitions,
1,5,9–13
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
present.
5
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.
2
Despite its strong predictive validity,
2,14,15
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
examination.
16,17
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.
12
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,
2
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.
Methods
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.
18–20
From the clinical
examinations we did within this cohort, we developed the rules-
based frailty definition
12
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
Abstract
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
(
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 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.
CMAJ
2005;173(5):489-95
DOI:10.1503/cmaj.050051
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.
21
Rooted in our
theoretical model of fitness and frailty
7
and the importance of
function (which we reported in earlier investigations),
12
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-
morbidity
1
(see Box 2).
12,23–26
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,
21
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
1
Very fit
robust, active, energetic, well motivated and
fit; these people commonly exercise regularly and are in
the most fit group for their age
2
Well
without active disease, but less fit than people in
category 1
3
Well, with treated comorbid disease
disease symptoms
are well controlled compared with those in category 4
4
Apparently vulnerable
although not frankly dependent,
these people commonly complain of being slowed up
or have disease symptoms
5
Mildly frail
with limited dependence on others for
instrumental activities of daily living
6
Moderately frail
help is needed with both instrumental
and non-instrumental activities of daily living
7
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
22
(3MS), in which
a score of 77 or less indicates cognitive impairment
Cumulative Illness Rating Scale,
23
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)
24
CSHA rules-based definition of frailty,
12
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
22
and outcomes of the CSHA Clinical Frailty Scale,
and the Cumulative Illness Rating Scale,
23
as well as the CSHA’s
Function Scale, rules-based frailty definition
12,16
and Frailty Index,
2
adjusting each for age, sex and years of education. Receiver oper-
ating characteristic (ROC) curves
27
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.
Results
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.
12,16
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
Characteristic
Very
fit
Well
Well, with treated
comorbid disease
Apparently
vulnerable
Mildly
frail
Moderately
frail
Severely
frail
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
Factor
Death,
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%–
41.2%).
Interpretation
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
frailty.
The Clinical Frailty Scale mixes
items such as comorbidity, cognitive im-
pairment and disability that some other
groups separate in focusing on physical
frailty.
3
Although support exists for sepa-
rate approaches,
28
consensus does not,
1,2
Rockwood et al
492 JAMC 30 AOÛT 2005; 173 (5)
6–7
(
691
)
Score
(
n
)
1–3
(
952
)
4
(
349
)
5
(
305
)
Time, mo
0.9
0.3
0.4
0.5
0.6
0.7
0.8
1.0
700102030405060
Probability of survival
0.9
0.3
0.4
0.5
0.6
0.7
0.8
1.0
700102030405060
Time, mo
Probability of avoidance
of institutional care
Score (
n
)
1–3 (
828
)
4 (
256
)
5 (
136
)
6–7 (
66
)
Fig. 1: Kaplan–Meier curves, adjusted for age and sex, for study participants (
n
)
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
29–32
and in any case
would be captured by our designation of being “apparently
vulnerable.”
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.
33–36
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.
15,37
For
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
version.
15
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,
2,38,39
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
Death
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.
Contributors
: 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.
References
1. Hogan DB, MacKnight C, Bergman H; Steering Committee, Canadian Ini-
tiative on Frailty and Aging. Models, definitions, and criteria of frailty [re-
view]. Aging Clin Exp Res 2003;15(3 Suppl):1-29.
2. Rockwood K, Mitnitski A, MacKnight C. Some mathematical models of
frailty and their clinical implications. Rev Clin Gerontol 2002;12:109-17.
3. Fried LP, Ferrucci L, Darer J, Williamson JD, Anderson G. Untangling the
concepts of disability, frailty, and comorbidity: implications for improved
targeting and care [review]. J Gerontol A Biol Sci Med Sci 2004;59:255-63.
4. Lipsitz LA. Physiological complexity, aging, and the path to frailty [review].
Sci Aging Knowledge Environ 2004;2004:pe16.
5. Fried LP, Tangen CM, Walston J, Newman AB, Hirsch C, Gottdiener J, et
al.; Cardiovascular Health Study Collaborative Research Group. Frailty in
older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci 2001;56:
M146-56.
6. Morley JE, Perry HM
III, Miller DK. Editorial: something about frailty [re-
view]. J Gerontol A Biol Sci Med Sci 2002;57:M698-704.
7. Rockwood K, Fox RA, Stolee P, Robertson D, Beattie BL. Frailty in elderly
people: an evolving concept [review]. CMAJ 1994;150(4):489-95.
8. Wells JL, Seabrook JA, Stolee P, Borrie MJ, Knoefel F. State of the art in
geriatric rehabilitation. Part I: review of frailty and comprehensive geriatric
assessment [review]. Arch Phys Med Rehabil 2003;84:890-7.
9. Chin A Paw MJ, Dekker JM, Feskens EJ, Schouten EG, Kromhout D. How
to select a frail elderly population? A comparison of three working defini-
tions. J Clin Epidemiol 1999;52:1015-21.
10. Strawbridge WJ, Shema SJ, Balfour JL, Higby HR, Kaplan GA. Antecedents
of frailty over three decades in an older cohort. J Gerontol B Psychol Sci Soc Sci
1998;53:S9-16.
11. Canadian Study of Health and Aging Working Group. Disability and frailty
among elderly Canadians: a comparison of six surveys. Int Psychogeriatr 2001;
13(Suppl 1):159-68.
12. Rockwood K, Stadnyk K, MacKnight C, McDowell I, Hébert R, Hogan DB.
A brief clinical instrument to classify frailty in elderly people [letter]. Lancet
1999;353(9148):205-6.
13. Chin A Paw MJ, de Groot LC, van Gend SV, Schoterman MH, Schouten
EG, Schroll M, et al. Inactivity and weight loss: effective criteria to identify
frailty. J Nutr Health Aging 2003;7:55-60.
14. Mitnitski AB, Song X, Rockwood K. The estimation of relative fitness and
frailty in community-dwelling older adults using self-report data. J Gerontol
A Biol Sci Med Sci 2004;59:M627-32.
15. Song X, Mitnitski A, MacKnight C, Rockwood K. Assessment of individual
risk of death using self-report data: an artificial neural network compared
with a Frailty Index. J Am Geriatr Soc 2004;52:1180-4.
16. Rockwood K, Howlett SE, MacKnight C, Beattie BL, Bergman H, Hebert
R, et al. Prevalence, attributes, and outcomes of fitness and frailty in commu-
nity-dwelling older adults: report from the Canadian Study of Health and
Aging. J Gerontol A Biol Sci Med Sci 2004;59:1310-7.
17. Jones DM, Song X, Rockwood K. Operationalizing a frailty index from a
standardized comprehensive geriatric assessment. J Am Geriatr Soc 2004;52:
1929-33.
18. CSHA Working Group. Canadian Study of Health and Aging: study meth-
ods and prevalence of dementia. CMAJ 1994;150(6):899-913.
19. CSHA Working Group. The incidence of dementia in Canada: the Canadian
Study of Health and Aging Working Group. Neurology 2000;55:66-73.
20. Rockwood K, Wolfson C, McDowell I. The Canadian Study of Health and
Aging: organizational lessons from a national, multicenter, epidemiologic
study. Int Psychogeriatr 2001;13(Suppl 1):233-7.
21. Streiner DL, Norman GR. Health measurement scales: a practical guide to their
development and use. 3rd ed. Oxford: Oxford University Press; 2003. p. 4-13.
22. Teng EL, Chui HC. The Modified Mini-Mental State (3MS) examination. J
Clin Psychiatry 1987;48:314-8.
23. Conwell Y, Forbes NT, Cox C, Caine ED. Validation of a measure of physi-
cal illness burden at autopsy: the Cumulative Illness Rating Scale. J Am Geri-
atr Soc 1993;41:38-41.
24. American Psychiatric Association. Diagnostic and statistical manual. 3rd ed, re-
vised. Washington: The Association; 1987.
25. Graham JE, Rockwood K, Beattie BL, Eastwood R, Gauthier S, Tuokko H,
et al. Prevalence and severity of cognitive impairment with and without de-
mentia in an elderly population. Lancet 1997;349:1793-6.
26. Ebly EM, Hogan DB, Parhad IM. Cognitive impairment in the nonde-
mented elderly: results from the Canadian Study of Health and Aging. Arch
Neurol 1995;52:612-9.
27. Metz CE. Basic principles of ROC analysis. Semin Nucl Med 1978;8:283-98.
28. Ferrucci L, Guralnik JM, Studenski S, Fried LP, Cutler GB Jr, Walston JD;
Interventions on Frailty Working Group. Designing randomized, controlled
trials aimed at preventing or delaying functional decline and disability in
frail, older persons: a consensus report. J Am Geriatr Soc 2004;52:625-34.
29. Nourhashemi F, Andrieu S, Gillette-Guyonnet S, Vellas B, Albarede JL,
Grandjean H. Instrumental activities of daily living as a potential marker of
frailty: a study of 7364 community-dwelling elderly women (the EPIDOS
study). J Gerontol A Biol Sci Med Sci 2001;56:M448-53.
30. Schuurmans H, Steverink N, Lindenberg S, Frieswijk N, Slaets JP. Old or
frail: What tells us more? J Gerontol A Biol Sci Med Sci 2004;59:M962-5.
31. Gill TM, Allore H, Holford TR, Guo Z. The development of insidious dis-
ability in activities of daily living among community-living older persons. Am
J Med 2004;117:484-91.
32. Binder EF, Schechtman KB, Ehsani AA, Steger-May K, Brown M, Sinacore
DR, et al. Effects of exercise training on frailty in community-dwelling older
adults: results of a randomized, controlled trial. J Am Geriatr Soc 2002;50:
1921-8.
33. Studenski S, Hayes RP, Leibowitz RQ, Bode R, Lavery L, Walston J, et al.
Clinical Global Impression of Change in Physical Frailty: development of a
measure based on clinical judgment. J Am Geriatr Soc 2004;52:1560-6.
34. Charlson ME, Sax FL, MacKenzie CR, Fields SD, Braham RL, Douglas RG
Jr. Assessing illness severity. Does clinical judgement work? J Chronic Dis
1986;39:439-52.
35. Charlson ME, Hollenberg JP, Hou J, Cooper M, Pochapin M, Pecker M.
Realizing the potential of clinical judgment: a real-time strategy for predict-
ing outcomes and cost for medical inpatients. Am J Med 2000;109:189-95.
36. Torres OH, Munoz J, Ruiz D, Ris J, Gich I, Coma E, et al. Outcome predic-
tors of pneumonia in elderly patients: importance of functional assessment. J
Am Geriatr Soc 2004;52:1603-9.
37. Song X, Mitnitski A, Cox J, Rockwood K. Comparison of machine learning
techniques with classical statistical models in predicting health outcomes.
Medinfo 2004;2004:736-40.
38. Mitnitski AB, Mogilner AJ, MacKnight C, Rockwood K. The accumulation
of deficits with age and possible invariants of aging. ScientificWorldJournal
2002;2:1816-22.
39. Rockwood K, Mogilner AJ, Mitnitski AB. Changes with age in the distribu-
tion of a frailty index. Mech Ageing Dev 2004;125:517-9.
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;
kenneth.rockwood@dal.ca
Acknowledgements
: 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
Falls
Mood problems
Feeling sad, blue, depressed
History of depressed mood
Tiredness all the time
Depression (clinical impression)
Sleep changes
Restlessness
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
Headache
Cerebrovascular problems
History of stroke
History of diabetes mellitus
Arterial hypertension
Peripheral pulses
Cardiac problems
Myocardial infarction
Arrhythmia
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
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by Sept. 13, 2005. The criteria for acceptable registration are
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CMAJ
(2005;172[13]:1700-2).
... 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]. ...
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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; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12621000379819p ). 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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... 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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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.
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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.
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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.