Response to the Letter to the Editor: “What Is Missing in the Validation of Frailty Instruments?”

Practitioner perceptions of the feasibility of common frailty screening instruments within general practice settings: a mixed methods study

BACKGROUND

Frailty is a highly prevalent clinical syndrome increasing older people's vulnerability to risk of adverse outcomes. Better frailty identification through expanded screening implementation has been advocated within general practice settings, both internationally and within Australia. However, little is known about practitioner perceptions of the feasibility of specific instruments, and the underlying motivations behind those perceptions. Consequently, the purpose of this study was to explore the attitudes and perceptions of a convenience and volunteer sample of Australian general practitioners (GPs) and practice nurses (PNs) towards common frailty screening instruments.

METHODS

The feasibility of several frailty screening instruments (PRISMA-7 [P7], Edmonton Frail Scale [EFS], FRAIL Questionnaire [FQ], Gait Speed Test [GST], Groningen Frailty Indicator [GFI], Kihon Checklist [KC] and Timed Up and Go [TUG]) to 43 Australian GPs and PNs was assessed. The study adopted a concurrent embedded mixed-methods design incorporating quantitative (ranking exercise) and qualitative (content analysis) data collection integrated during the analysis phase.

RESULTS

Practitioners assessed multi-dimensional instruments (EFS, GFI, KC) as having relatively higher clinical utility, better integration into existing assessment processes and stronger links to intervention over uni-dimensional (GST, TUG) and simple (FQ, P7) instruments.

CONCLUSIONS

While existing frailty screening instruments show promise as an initial step in supporting better care for older people, all the included instruments were associated with perceived advantages and disadvantages. Ultimately, clinicians will need to weigh several factors in their selection of the optimal screening instrument. Further translational research, with a focus on contextual fit, is needed to support clinical decision-making on the selection of instruments for frailty screening.

Feasibility, acceptability and diagnostic test accuracy of frailty screening instruments in community-dwelling older people within the Australian general practice setting: a study protocol for a cross-sectional study

INTRODUCTION

Frailty is one of the most challenging aspects of population ageing due to its association with increased risk of poor health outcomes and quality of life. General practice provides an ideal setting for the prevention and management of frailty via the implementation of preventive measures such as early identification through screening.

METHODS AND ANALYSIS

Our study will evaluate the feasibility, acceptability and diagnostic test accuracy of several screening instruments in diagnosing frailty among community-dwelling Australians aged 75+ years who have recently made an appointment to see their general practitioner (GP). We will recruit 240 participants across 2 general practice sites within South Australia. We will invite eligible patients to participate and consent to the study via mail. Consenting participants will attend a screening appointment to undertake the index tests: 2 self-reported (Reported Edmonton Frail Scale and Kihon Checklist) and 5 (Frail Scale, Groningen Frailty Index, Program on Research for Integrating Services for the Maintenance of Autonomy (PRISMA-7), Edmonton Frail Scale and Gait Speed Test) administered by a practice nurse (a Registered Nurse working in general practice). We will randomise test order to reduce bias. Psychosocial measures will also be collected via questionnaire at the appointment. A blinded researcher will then administer two reference standards (the Frailty Phenotype and Adelaide Frailty Index). We will determine frailty by a cut-point of 3 of 5 criteria for the Phenotype and 9 of 42 items for the AFI. We will determine accuracy by analysis of sensitivity, specificity, predictive values and likelihood ratios. We will assess feasibility and acceptability by: 1) collecting data about the instruments prior to collection; 2) interviewing screeners after data collection; 3) conducting a pilot survey with a 10% sample of participants.

ETHICS AND DISSEMINATION

The Torrens University Higher Research Ethics Committee has approved this study. We will disseminate findings via publication in peer-reviewed journals and presentation at relevant conferences.

The need of operational paradigms for frailty in older persons: the SPRINTT project

The exploration of frailty as a pre-disability geriatric condition represents one of the most promising research arenas of modern medicine. Frailty is today indicated as a paradigmatic condition around which the traditional healthcare systems might be re-shaped and optimized in order to address the complexities and peculiarities of elders. Unfortunately, the lack of consensus around a single operational definition has limited the clinical implementation of frailty in clinical practice. In these last years, growing attention (even beyond the traditional boundaries of geriatric medicine) has been given to physical performance measures. These instruments have shown to be predictive of negative health-related events and able to support an accurate estimation of the "biological age" in late life. The strong construct of physical performance measures also makes them particularly suitable for the assessment of the frailty status. Furthermore, the adoption of physical performance measures may help render the frailty condition more organ-specific (i.e., centred on the skeletal muscle quality) and less heterogeneous than currently perceived. The translation of the frailty concept by means of physical performance measures implicitly represents an attempt to go beyond traditional paradigms. In this context, the recently funded "Sarcopenia and Physical fRailty IN older people: multi-componenT Treatment strategies" (SPRINTT) project (largely based on such a novel approach) may indeed fill an important gap in the field and provide key insights for counteracting the disabling cascade in the elderly.

Implementing Frailty Screening, Assessment, and Sustained Intervention: The experience of the Gérontopôle

Despite its interest, frailty is not yet adequately implemented in the everyday clinical practice. Frailty is characterized by an initial functional loss which 1) still allows the individual to be independent in the daily life (although with some difficulties), and 2) may be reversed by targeted interventions. In the present article, we discuss: Why frailty is clinically relevant? Why frailty has not yet been implemented in daily clinical practice? How to implement frailty into clinical practice following the Gérontopôle experience? Intervention to be effective must be targeted, strong, and maintained.