The predictive validity of three self-report screening instruments for identifying frail older people in the community

Global frailty screening tools: Review and application of frailty screening tools from 2001 to 2023

As the aging population increases globally, health-related issues caused by frailty are gradually coming to light and have become a global health priority. Frailty leads to a significantly increased risk of falls, incapacitation, and death. Early screening leads to better prevention and management of frailty, increasing the possibility of reversing it. Developing assessment tools by incorporating disease states of older adults using effective interventions has become the most effective approach for preventing and controlling frailty. The most direct and effective tool for evaluating debilitating conditions is a frailty screening tool, but because there is no globally recognized gold standard, every country has its own scale for national use. The diversity and usefulness of the frailty screening tool has become a hot topic worldwide. In this article, we reviewed the frailty screening tool published worldwide from January 2001 to June 2023. We focused on several commonly used frailty screening tools. A systematic search was conducted using PubMed database, and the commonly used frailty screening tools were found to be translated and validated in many countries. Disease-specific scales were also selected to fit the disease. Each of the current frailty screening tools are used in different clinical situations, and therefore, the clinical practice applications of these frailty screening tools are summarized graphically to provide the most intuitive screening and reference for clinical practitioners. The frailty screening tools were categorized as (ⅰ) Global Frailty Screening Tools in Common; (ⅱ) Frailty Screening Tools in various countries; (ⅲ) Frailty Screening Tools for various diseases. As science and technology continue to advance, electronic frailty assessment tools have been developed and utilized. In the context of Coronavirus disease 2019 (COVID-19), electronic frailty assessment tools played an important role. This review compares the currently used frailty screenings tools, with a view to enable quick selection of the appropriate scale. However, further improvement and justification of each tool is needed to guide clinical practitioners to make better decisions.

Turkish translation, cross-cultural adaptation and reliability of the Groningen Frailty Indicator

BACKGROUND

Frailty is an important geriatric syndrome that can be seen as a way of recognizing and distinguishing the complex health conditions of older people. Due to the time limitation, short and simple instruments are most feasible in clinical practice, and several quick screening tools have been developed and validated, Groningen frailty indicator (GFI) is one of these scales. We aimed to validate and evaluate the reliability of the GFI in outpatient older adults in the Turkish population.

METHODS

A total of 101 older patients were enrolled to the study. GFI was scored by a geriatrician for every patient at first admission to the geriatric outpatient clinic. Fried Physical Frailty Phenotype (FPFP) was performed as a reference test.

RESULTS

The median age (IQR) was 72.0 (10.0) and 62.4% of the study population (n = 63) was female. Based on the GFI, 34 patients (33.7%) were defined as robust, and 67 patients (66.3%) were defined as living with frailty. There was a statistically significant concordance between GFI and FPFP (Cohen's kappa: 0.415 p < 0.001). GFI had excellent consistency in inter-rater reliability (Cronbach's alpha: 0.99, 95% CI 0.97-1.00) and in intra-rater reliability (Cronbach's alpha: 0.99, 95% CI 0.96-1.0).

CONCLUSION

Our study showed that GFI is a valid and reliable scale in the Turkish older population.

A review of frailty instruments in human medicine and proposal of a frailty instrument for dogs

Over the last few decades, frailty has become a pillar of research and clinical assessment in human gerontology. This complex syndrome, characterized by loss of physiologic reserves leading to decreased resilience to stressors, is of critical importance because it predicts higher risks of poor health outcomes, including mortality. Thus, identifying frailty among the elderly human population has become a key focus of gerontology. This narrative review presents current scientific literature on frailty in both humans and animals. The authors discuss the need for an accessible frailty instrument for companion dogs suitable for general use in veterinary medicine and the advances that would be facilitated by this instrument. A phenotypic frailty instrument for companion dogs, utilizing components that are easily collected by owners, or in the general practice setting, is proposed. The authors elaborate on the domains (physical condition, physical activity, mobility, strength, cognitive task performance, and social behavior), factors that will be included, and the data from the Dog Aging Project that inform each domain.

Frailty Viewed From a Nursing Perspective

Introduction

More and more researchers are convinced that frailty should refer not only to physical limitations but also to psychological and social limitations that older people may have. Such a broad, or multidimensional, definition of frailty fits better with nursing, in which a holistic view of human beings, and thus their total functioning, is the starting point.

Purpose

In this article, which should be considered a Practice Update, we aim at emphasizing the importance of the inclusion of other domains of human functioning in the definition and measurement of frailty. In addition, we provide a description of how district nurses view frailty in older people. Finally, we present interventions that nurses can perform to prevent or delay frailty or its adverse outcomes. We present, in particular, results from studies in which the Tilburg Frailty Indicator, a multidimensional frailty instrument, was used.

Conclusion

The importance of a multidimensional assessment of frailty was demonstrated by usually satisfactory results concerning adverse outcomes of mortality, disability, an increase in healthcare utilization, and lower quality of life. Not many studies have been performed on nurses' opinions about frailty. Starting from a multidimensional definition of frailty, encompassing physical, psychological, and social domains, nurses are able to assess and diagnose frailty and conduct a variety of interventions to prevent or reduce frailty and its adverse effects. Because nurses come into frequent contact with frail older people, we recommend future studies on opinions of nurses about frailty (e.g., screening, prevention, and addressing).

Validating the Centre of Excellence on Longevity Self-AdMinistered (CESAM) Questionnaire: An Online Self-Reported Tool for Frailty Assessment of Older Adults

OBJECTIVES

Subjective health measures are often used to assess frailty, but the validity of self-reported online tools to identify frailty remains to be established. We aimed to assess concurrent, known-groups, convergent and predictive validity of the Centre of Excellence on Longevity Self-AdMinistered (CESAM) questionnaire for frailty assessment of older adults in an outpatient setting.

DESIGN

Cross-sectional analysis of 120 participants.

SETTING AND PARTICIPANTS

Participants of age ≥65 were recruited from an outpatient geriatric clinic. Individuals who had severe neurological, cognitive, or motor deficits were excluded.

METHODS

We assessed concurrent validity with area under receiver operating characteristic curve (AUC) against the Frailty Index (FI) and Clinical Frailty Scale (CFS). We analyzed known-groups validity between CESAM scores with frailty status (CFS and FI), Modified Barthel Index (MBI), and modified Chinese Mini-Mental State Examination (mCMMSE) using 1-way analysis of variance. We evaluated convergent validity using correlations with MBI, the Lawton index, mCMMSE, and Geriatric Depression Scale (GDS). Associations between CESAM-identified frailty for clinician-diagnosed geriatric syndromes, and health-related quality of life (HRQoL) was analyzed using regression analysis.

RESULTS

The CESAM questionnaire demonstrated excellent diagnostic performance for frailty using FI ≥0.25 (AUC = 0.88; 95% CI: 0.82-0.94; P < .001) and CFS ≥4 (AUC = 0.78; 95% CI: 0.68-0.88; P < .001). CESAM scores increased significantly with increasing frailty (both CFS and FI), lower MBI, and lower mCMMSE scores (all P < .001), indicating concurrent validity. The moderate-good correlation of CESAM scores with MBI (r = -0.61; P < 0.001), Lawton Index (r = -0.54; P < .001), mCMMSE (r = -0.53; P < .001) and GDS (r = 0.58; P < .001) supports convergent validity. Using a cutoff of ≥8 for frailty identification, CESAM-identified frailty was associated with cognitive impairment (OR = 3.7; 95% CI: 1.7-8.2; P = .001) depression (OR = 4.0; 95% CI: 1.7-9.6; P = .002), falls (OR = 3.1; 95% CI: 1.2-8.2; P = .021) and poorer HRQoL (β = -0.1; 95% CI: -0.2 to -0.02; P = .017).

CONCLUSION AND IMPLICATIONS

Our results support the validity of an online self-reported tool to identify frailty and geriatric syndromes in an outpatient setting, an approach that is potentially applicable for remote screening of frailty.

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

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

Development and Validation of the Chinese Frailty Screening Scale: A Study among Community-Dwelling Older Adults in Shanghai

BACKGROUND

Based on intrinsic capacity (IC) as defined by the World Health Organization, an accelerated decline may be an important precursor of frailty among older adults; however, there is a lack of validated instruments that both screen for frailty and monitor IC. This study aims to develop a comprehensive and acculturative frailty screening scale to determine healthy aging among older Chinese adults.

SETTING AND PARTICIPANTS

A cross-sectional and a cohort study both based on community-dwelling older adults aged 65 and older.

METHODS

This study mainly consisted of two parts. First, the selection and revision of 20 items related to frailty based on a literature review, expert consultation, and stakeholder analysis; second, a cross-sectional study was conducted to simplify the scale and test the reliability and validity of the new frailty screening tool. The fatigue, resistance, ambulation, illness, and loss of weight (FRAIL) scale, the Tilburg frailty indictor (TFI), and a 49-item Frailty Index (FI) were investigated as criteria. Additionally, a cohort study in Shanghai was conducted to verify the predictive validity of the new screening scale. The disability measured by the activity of daily living (ADL), instrumental activity of daily living (IADL) and all-cause mortality were documented as outcomes.

RESULTS

A 10-item Chinese frailty screening scale (CFSS-10) was successfully developed and validated. It presented a Cronbach's α of 0.63 and an intraclass correlation coefficient of 0.73, which indicated good reliability. Taking the other frailty tools as criteria, Kappa values of 0.54-0.58 and an area under the curve of 0.87-0.91 showed good validity. The results of the log-binomial and Poisson models showed a high score, which predicted a higher risk of disability and all-cause mortality. An optimal cut-off point of 5 gave an excellent prediction of one-year disability.

CONCLUSIONS

The CFSS-10 has good validity and reliability as a quick and acculturative frailty screening scale for community-dwelling older adults in Shanghai. It may also supplement existing frailty screening tools.

Construct Validity of a New Health Assessment Questionnaire for the National Screening Program of Older Adults in Japan: The SONIC Study

The Japanese government has implemented a new screening program to promote measures to avoid worsening lifestyle-related diseases and frailty among the older population. In this effort, the government formulated a new health assessment questionnaire for the screening program of old-old adults aged ≥75 years. The questionnaire comprises 15 items, of which 12 address frailty, two address general health status, and one addresses smoking habits. This study examined the construct validity of this questionnaire, using the explanatory factor analysis (EFA) and confirmatory factor analysis (CFA). The data used in this study were drawn from a mail-in survey conducted in 2020 as part of the Septuagenarians, Octogenarians, Nonagenarians Investigation with Centenarians study. A total of 1576 respondents (range, 78-99 years of age) were included in the study. Although the EFA did not show an interpretable factor structure of the questionnaire with 15 items, the CFA using only 12 frailty-related items showed the goodness of fit for a higher-order factor "frailty", and the five frailty-related sub-factors model was acceptable. These results suggest that the total score of the 12 frailty-related items in the questionnaire can be used as an indicator of the degree of "frailty".

The ability of eight frailty instruments to identify adverse outcomes across different settings: the FRAILTOOLS project

BACKGROUND

To compare the performance of eight frailty instruments to identify relevant adverse outcomes for older people across different settings over a 12 month follow-up.

METHODS

Observational longitudinal prospective study of people aged 75 + years enrolled in different settings (acute geriatric wards, geriatric clinic, primary care clinics, and nursing homes) across five European cities. Frailty was assessed using the following: Frailty Phenotype, SHARE-FI, 5-item Frailty Trait Scale (FTS-5), 3-item FTS (FTS-3), FRAIL scale, 35-item Frailty Index (FI-35), Gérontopôle Frailty Screening Tool, and Clinical Frailty Scale. Adverse outcomes ascertained at follow-up were as follows: falls, hospitalization, increase in limitation in basic (BADL) and instrumental activities of daily living (IADL), and mortality. Sensitivity, specificity, and capacity to predict adverse outcomes in logistic regressions by each instrument above age, gender, and multimorbidity were calculated.

RESULTS

A total of 996 individuals were followed (mean age 82.2 SD 5.5 years, 61.3% female). In geriatric wards, the FI-35 (69.1%) and the FTS-5 (67.9%) showed good sensitivity to predict death and good specificity to predict BADL worsening (70.3% and 69.8%, respectively). The FI-35 also showed good sensitivity to predict BADL worsening (74.6%). In nursing homes, the FI-35 and the FTSs predicted mortality and BADL worsening with a sensitivity > 73.9%. In geriatric clinic, the FI-35, the FTS-5, and the FRAIL scale obtained specificities > 85% to predict BADL worsening. No instrument achieved high enough sensitivity nor specificity in primary care. All the instruments predict the risk for all the outcomes in the whole sample after adjusting for age, gender, and multimorbidity. The associations of these instruments that remained significant by setting were for BADL worsening in geriatric wards [FI-35 OR = 5.94 (2.69-13.14), FTS-3 = 3.87 (1.76-8.48)], nursing homes [FI-35 = 4.88 (1.54-15.44), FTS-5 = 3.20 (1.61-6.38), FTS-3 = 2.31 (1.27-4.21), FRAIL scale = 1.91 (1.05-3.48)], and geriatric clinic [FRAIL scale = 4.48 (1.73-11.58), FI-35 = 3.30 (1.55-7.00)]; for IADL worsening in primary care [FTS-5 = 3.99 (1.14-13.89)] and geriatric clinic [FI-35 = 3.42 (1.56-7.49), FRAIL scale = 3.27 (1.21-8.86)]; for hospitalizations in primary care [FI-35 = 3.04 (1.25-7.39)]; and for falls in geriatric clinic [FI-35 = 2.21 (1.01-4.84)].

CONCLUSIONS

No single assessment instrument performs the best for all settings and outcomes. While in inpatients several commonly used frailty instruments showed good sensitivities (mainly for mortality and BADL worsening) but usually poor specificities, the contrary happened in geriatric clinic. None of the instruments showed a good performance in primary care. The FI-35 and the FTS-5 showed the best profile among the instruments assessed.

The Tilburg Frailty Indicator: A psychometric systematic review

BACKGROUND

The Tilburg Frailty Indicator (TFI) is one of the most prominent multidimensional frailty assessment instruments. This review aimed to critically appraise and summarise its measurement properties.

METHODS

Reports were eligible if they included results of studies aimed at developing the TFI or evaluating its measurement properties. We performed a literature search in MEDLINE, CINAHL, and PsycINFO databases from their inception until December 8, 2021. We also searched grey literature databases. We assessed the methodological quality of the included studies using the "COSMIN Risk of Bias". The measurement properties were evaluated using specific criteria. We graded the quality of the evidence using a GRADE approach.

RESULTS

Sixty-three studies were included. We found moderate sufficient evidence for TFI content validity, although it is still insufficient for the comprehensiveness of its items. TFI construct validity was based on sufficient evidence from two studies of its structural validity as well as multiple hypothesis-testing for construct validity studies with inconsistent results. We did not find any studies that assessed cross-cultural validity. Only one of TFI's three dimensions showed sufficient evidence for the internal consistency of its scores, and results in test-retest reliability were inconsistent. The TFI showed high sufficient concurrent validity with the comprehensive geriatric assessment. We identified several studies assessing its predictive validity for adverse frailty-related outcomes, although most of the evidence from these studies was insufficient. We did not find any studies that assessed the responsiveness of TFI scores.

CONCLUSIONS

The TFI had evidence gaps in several relevant measurement properties. Further research is needed to strengthen its usefulness as a clinical decision-making tool.

Exploring associations between multidimensional frailty and oral health in community-dwelling older people. A pilot study

Objective

To determine the associations between four validated multidimensional self‐report frailty scales and nine indices of oral health in community‐dwelling older persons.

Materials and Methods

This pilot study was conducted in a sample of 208 older persons aged 70 years and older who visited two dental practices in the Netherlands. Frailty status was measured by four different self‐report frailty questionnaires: Tilburg Frailty Indicator (TFI), Groningen Frailty Indicator (GFI), Sunfrail Checklist (SC), and the Sherbrooke Postal Questionnaire (SPQ). Oral health was assessed by two calibrated examiners.

Results

The prevalence of frailty according to the four frailty measures TFI, GFI, SC, and SPQ was 32.8%, 31.5%, 24.5%, and 49.7%, respectively. The SC correlated with four oral health variables (DMFT, number of teeth, percentage of occlusal contacts, Plaque Index), the TFI with three (number of teeth, percentage of occlusal contacts, Plaque Index), the GFI only with DPSI, and the SPQ with the number of teeth and the number of occlusal contacts.

Conclusion

Of the studied multidimensional frailty scales, the SC and TFI were correlated with most oral health variables (four and three, respectively). However, it should be noticed that these correlations were small.

Clinical relevance

The SC and TFI might help to identify older people with risk of poor oral health so that preventive care can be used to ensure deterioration of oral health and maintenance of quality of life. Vice versa early detection of frailty by oral care professionals could contribute to interprofessional management of frailty.

Mapping instruments for assessing and stratifying frailty among community-dwelling older people: a scoping review

OBJECTIVE

To map in the current literature instruments for the assessment and stratification of frailty in community-dwelling older people, as well as to analyse them from the perspective of the Brazilian context.

DESIGN

Scoping review.

STUDY SELECTION

The selection of studies took place between March and April 2020. Includes electronic databases: Medline, Latin American and Caribbean Literature in Health Sciences, Scopus, Web of Science and Cumulative Index of Nursing and Literature Health Alliance, in addition to searching grey literature.

DATA EXTRACTION

A data extraction spreadsheet was created to collect the main information from the studies involved, from the title to the type of assessment and stratification of frailty.

RESULTS

In summary, 17 frailty assessment and stratification instruments applicable to community-dwelling older people were identified. Among these, the frailty phenotype of Fried et al was the instrument most present in the studies (45.5%). The physical domain was present in all the instruments analysed, while the social, psychological and environmental domains were present in only 10 instruments.

CONCLUSIONS

This review serves as a guideline for primary healthcare professionals, showing 17 instruments applicable to the context of the community-dwelling older people, pointing out advantages and disadvantages that influence the decision of the instrument to be used. Furthermore, this scoping review was a guide for further studies carried out by the same authors, which aim to compare instruments.

Identifying and Managing Malnutrition, Frailty and Sarcopenia in the Community: A Narrative Review

Malnutrition, frailty and sarcopenia are becoming increasingly prevalent among community-dwelling older adults; yet are often unidentified and untreated in community settings. There is an urgent need for community-based healthcare professionals (HCPs) from all disciplines, including medicine, nursing and allied health, to be aware of, and to be able to recognise and appropriately manage these conditions. This paper provides a comprehensive overview of malnutrition, frailty and sarcopenia in the community, including their definitions, prevalence, impacts and causes/risk factors; and guidance on how these conditions may be identified and managed by HCPs in the community. A detailed description of the care process, including screening and referral, assessment and diagnosis, intervention, and monitoring and evaluation, relevant to the community context, is also provided. Further research exploring the barriers/enablers to delivering high-quality nutrition care to older community-dwelling adults who are malnourished, frail or sarcopenic is recommended, to inform the development of specific guidance for HCPs in identifying and managing these conditions in the community.

Understanding Frailty Screening: a Domain Mapping Exercise

Background

Many definitions and operationalisations of frailty exclude psychosocial factors, such as social isolation and mental health, despite considerable evidence of the links between frailty and these factors. This study aimed to investigate the health domains covered by frailty screening tools.

Methods

A systematic search of the literature was conducted in accordance with PRISMA guidelines. MEDLINE, CINAHL, EMBASE, and PsycInfo were searched from inception to December 31, 2018. Data related to the domains of each screening tool were extracted and mapped onto a framework based on the biopsychosocial model of Lehmans et al. (2009) and Wade & Halligans (2017).

Results

Sixty-seven frailty screening tools were captured in 79 articles. All screening tools assessed biological factors, 73% assessed psychological factors, 52% assessed social factors, and 78% assessed contextual factors. Under half (43%) of the tools evaluated all four domains, 33% evaluated three of four domains, 12% reported two of four domains, and 13% reported one domain (biological).

Conclusion

This review found considerable variation in the assessment domains covered by frailty screening tools. Frailty is a broad construct, and frailty screening tools need to cover a wide variety of domains to enhance screening and outcomes assessment.

Assessing Frailty with the Tilburg Frailty Indicator (TFI): A Review of Reliability and Validity

Objective

The Tilburg Frailty Instrument (TFI) is an instrument for assessing frailty in community-dwelling older people. Since its development, many studies have been carried out examining the psychometric properties. The aim of this study was to provide a review of the main findings with regard to the reliability and validity of the TFI.

Methods

We conducted a literature search in the PubMed and CINAHL databases on May 30, 2020. An inclusion criterion was the use of the entire TFI, part B, referring to the 15 components. No restrictions were placed on language or year of publication.

Results

In total, 27 studies reported about the psychometric properties of the TFI. By far, most of the studies (n = 25) were focused on community-dwelling older people. Many studies showed that the internal consistency and test–retest reliability are good, which also applies for the criterion and construct validity. In many studies, adverse outcomes of interest were disability, increased health-care utilization, lower quality of life, and mortality. Regarding disability, studies predominantly show results that are excellent, with an area under the curve (AUC) >0.80. In addition, the TFI showed good associations with lower quality of life and the findings concerning mortality were at least acceptable. However, the association of the TFI with some indicators of health-care utilization can be indicated as poor (eg, visits to a general practitioner, hospitalization).

Conclusion

Since population aging is occurring all over the world, it is important that the TFI is available and well known that it is a user-friendly instrument for assessing frailty and its psychometric properties being qualified as good. The findings of this assessment can support health-care professionals in selecting interventions to reduce frailty and delay its adverse outcomes, such as disability and lower quality of life.

Understanding frailty among older people living in old age homes and the community in Nepal: A cross-sectional study

Introduction

Frailty is a state of being vulnerable to adverse health outcomes such as falls, delirium, and disability in older people. Identifying frailty is important in a low-income setting to prevent it from progressing, reducing healthcare costs, increasing the chances of reversibility, and implementing effective interventions. The factors affecting frailty in older people living in old age homes could differ from those living in the community. This study was conducted to identify the factors associated with frailty in older people residing in old age homes and communities in Kathmandu Valley, Nepal.

Methods

This is a cross-sectional study conducted from April to June 2019 in three districts of Kathmandu Valley, Nepal. Data were collected from 193 older people residing in old age homes and 501 residing in communities aged 60 and above using convenience sampling. Frailty was measured using the Groningen Frailty Indicator. Data were collected via face-to-face interviews. Multiple linear regression analyses were used to examine the association between independent variables and frailty.

Results

Frailty was more prevalent among older people in old age homes (71.5%) compared to those in the community (56.3%). Older people who were satisfied with their living environment had lower frailty scores in both old age homes (β = -0.20, p<0.01) and the community (β = -0.15, p<0.001). Those who had self-rated unhealthy lifestyle had higher frailty scores in both old age homes (β = 0.45, p<0.001) and the community (β = 0.25, p<0.001). In the community, those over 80 years of age had higher frailty scores (β = 0.15, p<0.01) and those with higher education had lower scores (β = -0.13, p<0.05).

Conclusion

The living environment and lifestyle are key modifiable risk factors of frailty, both in old age homes and the community. The findings suggest a need for lifestyle modification and reforms in building standards, especially in old age homes, to promote age-friendly communities.

A Comprehensive Overview of Activities of Daily Living in Existing Frailty Instruments: A Systematic Literature Search

BACKGROUND AND OBJECTIVES

The relationship between frailty and disability in activities of daily living (ADLs) can be seen in different ways, with disability being-to varying degrees-a characteristic, negative outcome, or predictor of frailty. This conflation of definitions is partly a result of the different frailty tools used in research. Aiming to provide a comprehensive overview, this systematic literature search analyzed (i) if, (ii) to what extent, and (iii) how ADLs are evaluated by frailty instruments.

RESEARCH DESIGN AND METHODS

A search was performed in PubMed, Web of Knowledge, and PsycINFO to identify all frailty instruments, followed by categorization of the ADL items into basic (b-), instrumental (i-), and advanced (a-) ADLs.

RESULTS

In total, 192 articles described 217 frailty instruments, from which 52.1% contained ADL items: 45.2% b-ADLs, 35.0% i-ADLs, and 10.1% a-ADLs. The most commonly included ADL items were bathing (b-ADLs); using transportation (i-ADLs); and semiprofessional work engagement in organized social life or leisure activities (a-ADLs). These instruments all had a multidomain origin (χ 2 = 122.4, p < .001).

DISCUSSION AND IMPLICATIONS

Because 52.1% of all instruments included ADL items, the concepts of frailty and disability appear to be highly entangled. This might lead to circular reasoning, serious concerns regarding contamination, and invalid research results.

[Clinical importance of the detection of frailty]

Frailty ist ein multidimensionales geriatrisches Syndrom, das durch einen Verlust an individueller Reservekapazität und eine erhöhte Vulnerabilität gegenüber internen und externen Stressoren gekennzeichnet ist. Frailty ist mit einem erhöhten Risiko für Stürze und einen Autonomieverlust sowie mit einer erhöhten Mortalität verbunden. Die Identifikation von Personen, die eine Frailty aufweisen, kann ein umfangreiches geriatrisches Assessment triggern und gezielte Therapieangebote begründen. Darüber hinaus können durch die Erfassung von Frailty jene Patient*innen identifiziert werden, die ein erhöhtes Risiko für ungünstige Behandlungsverläufe haben. Für die Erfassung von Frailty gibt es eine unübersichtliche Zahl an Instrumenten, wobei nur eine eingeschränkte Auswahl dieser Instrumente in einer deutschen Version vorliegt. Die Wahl des Instruments sollte sich am klinischen Setting und den vorhandenen Ressourcen orientieren.

Commonly Used Screening Instruments to Identify Frailty Among Community-Dwelling Older People in a General Practice (Primary Care) Setting: A Study of Diagnostic Test Accuracy

BACKGROUND

Rapid frailty screening remains problematic in primary care. The diagnostic test accuracy (DTA) of several screening instruments has not been sufficiently established. We evaluated the DTA of several screening instruments against two reference standards: Fried's Frailty Phenotype [FP] and the Adelaide Frailty Index [AFI]), a self-reported questionnaire.

METHODS

DTA study within three general practices in South Australia. We randomly recruited 243 general practice patients aged 75+ years. Eligible participants were 75+ years, proficient in English and community-dwelling. We excluded those who were receiving palliative care, hospitalized or living in a residential care facility.We calculated sensitivity, specificity, predictive values, likelihood ratios, Youden Index and area under the curve (AUC) for: Edmonton Frail Scale [EFS], FRAIL Scale Questionnaire [FQ], Gait Speed Test [GST], Groningen Frailty Indicator [GFI], Kihon Checklist [KC], Polypharmacy [POLY], PRISMA-7 [P7], Reported Edmonton Frail Scale [REFS], Self-Rated Health [SRH] and Timed Up and Go [TUG]) against FP [3+ criteria] and AFI [>0.21].

RESULTS

We obtained valid data for 228 participants, with missing scores for index tests multiply imputed. Frailty prevalence was 17.5% frail, 56.6% prefrail [FP], and 48.7% frail, 29.0% prefrail [AFI]. Of the index tests KC (Se: 85.0% [70.2-94.3]; Sp: 73.4% [66.5-79.6]) and REFS (Se: 87.5% [73.2-95.8]; Sp: 75.5% [68.8-81.5]), both against FP, showed sufficient diagnostic accuracy according to our prespecified criteria.

CONCLUSIONS

Two screening instruments-the KC and REFS, show the most promise for wider implementation within general practice, enabling a personalized approach to care for older people with frailty.

Predictive performance of 7 frailty instruments for short-term disability, falls and hospitalization among Chinese community-dwelling older adults: A prospective cohort study

BACKGROUND

Frailty becomes a great challenge with population aging. The proactive identification of frailty is considered as a rational solution in the community. Previous studies found that frailty instruments had insufficient predictive accuracy for adverse outcomes, but they mainly focused on long-term outcomes and constructed frailty instruments based on available data not original forms. The predictive performance of original frailty instruments for short-term outcomes in community-dwelling older adults remains unknown.

OBJECTIVE

To examine the predictive performance of seven frailty instruments in their original forms for 1-year incident outcomes among community-dwelling older adults.

DESIGN

A prospective cohort study.

SETTINGS

A total of 22 communities were selected by a stratified sampling method from one Chinese city.

PARTICIPANTS

A total of 749 older adults aged ≥ 60 years (mean age of 69.2 years, 69.8% female) were followed up after 1 year.

METHODS

Baseline frailty was assessed by three purely physical dimensional instruments (i.e. Frailty Phenotype, the Study of Osteoporotic Fracture and FRAIL Scale) and four multidimensional instruments (i.e. Frailty Index, Groningen Frailty Indicator, Tilburg Frailty Indicator and Comprehensive Frailty Assessment Instrument), respectively. Outcomes included incident disability, falls, hospitalization and the combined outcome at 1-year follow-up. The receiver operating characteristic curves were plotted to assess the predictive performance of frailty instruments.

RESULTS

The areas under the curves of seven frailty instruments in predicting incident outcomes ranged from 0.55 [95% confidence interval (CI): 0.51-0.60] to 0.67 (95% CI: 0.61-0.72), with high specificity (72.3-99.2%) and low sensitivity (4.0-49.6%). Four multidimensional instruments had much higher sensitivity (20.9-49.6% versus 4.0-11.7%) than three purely physical dimensional instruments. Overall, the Frailty Index was more accurate than some instruments in predicting incident outcomes, while several self-report instruments had comparable predictive accuracy to the Frailty Index for all (FRAIL Scale) or some (Groningen Frailty Indicator and Tilburg Frailty Indicator) of the incident outcomes.

CONCLUSIONS

All frailty instruments have inadequate predictive accuracy for short-term outcomes among community-dwelling older adults. The Frailty Index roughly performs better but self-report instruments are comparable to the Frailty Index for all or some of the outcomes. An accurate frailty instrument needs to be developed, and the simple self-report instruments could be used temporarily as practical and efficient tools in primary care.

Nutritional domains in frailty tools: Working towards an operational definition of nutritional frailty

Different methods have been proposed for the assessment of the nutritional status in frailty phenotypes. In the present narrative review article, we have summarized the number and specifications of nutritional items in existing frailty tools, in order to develop a possible means of assessment and operational definition of the nutritional frailty phenotype. In six different databases until December 2019, we searched for original articles regarding frailty tools (i.e., scales, indexes, scores, questionnaires, instruments, evaluations, screening, indicators), analyzing each tool regarding nutritional items. We identified 160 articles describing 71 frailty tools. Among the selected frailty tools, 54 were community-based (70 %), 17 hospital-based (22 %), 4 validated in long-term care institutions for older adults (LTCIOA) (5.1 %) and 2 validated in both community- and hospital-based settings, including LTCIOA (2.5 %). Fifty-two of these tools (73 %) included at least one nutritional item. Twenty-two (42 %) reported two or more nutritional items. The items were grouped in the following categories: A) anthropometric measurements, B) laboratory measurements, and C) other nutritional-related measurements. Anthropometric measurements stood out compared to all other items. Nutritional items are included in the majority of frailty tools, strengthening the concept that they may have a direct implication on an increased risk of adverse health-related outcomes in frail subjects. This supports the development of the concept of nutritional frailty as an independent frailty phenotype. Subsequent steps will be to assess the contribution of each nutritional item to a possible operational definition of nutritional frailty and define the items that may best identify this new frailty phenotype.

Usefulness of eight screening tools for predicting frailty and postoperative short- and long-term outcomes among older patients with cancer who qualify for abdominal surgery

INTRODUCTION

The aim of this study was to compare the ability of eight frailty screening scores to predict short- (30-day major morbidity and mortality), long-term outcomes (12-month mortality) and to compare their accuracy for predicting frailty among older patients with cancer undergoing elective abdominal surgery with curative intent.

MATERIALS AND METHODS

Consecutive patients aged ≥70 years were enrolled prospectively. The diagnostic performance of eight screening tests were evaluated: The Vulnerable Elderly Survey (VES-13), Triage Risk Screening Tool (TRST), Geriatric 8 (G8), Groningen Frailty Index (GFI), abbreviated Comprehensive Geriatric Assessment (aCGA), Rockwood, Balducci and Fried score. Frailty was defined based on the Geriatric Assessment (GA) with two (2ID) or three impaired domains (3ID).

RESULTS

The study included 269 consecutive patients; median age 78 (range 70-94) years. The prevalence of frailty based on the reference GA was: 40.9% (2ID), 34.2% (3ID) and using screening tools 40-75.5%. The area under the curve (AUC) for predicting the postoperative outcome was: 0.58-0.75 (30-day morbidity), 0.54-0.71 (30-day mortality) and 0.59-0.74 (12-month mortality), respectively, being the highest for the G8. The AUC for the frailty screening tests was: 0.67-0.85 (at the 2ID) and 0.63-0.83 (at the 3ID), being the highest for the aCGA.

CONCLUSION

The G8 was the best predictor of 30-day major morbidity, 30-day and 12-month mortality. It also had the highest sensitivity and negative predictive value in frailty screening, in case of both frailty definitions. In turn, the aCGA had the highest discriminatory ability in terms of frailty screening.

Cross-cultural adaptation and validation of the Groningen Frailty Indicator in Chinese nursing home residents

BACKGROUND

Frail older people are more likely to develop negative health outcomes. Previous studies have indicated that the Groningen Frailty Indicator is a practical frailty screening instrument with good psychometric properties; however, it has never been implemented in Chinese nursing homes.

AIMS

To cross-culturally adapt and validate the Groningen Frailty Indicator in Chinese nursing home residents.

METHODS

The participants were 192 residents from nursing homes. Reliability was analyzed by internal consistency and test-retest methods. Convergent validity was assessed using Spearman rank correlations between the GFI domains and activities of daily living, the mini nutritional assessment, the Mini-mental state examination, the Social Support Rating Scale, the 20-item Epidemiologic Studies Depression Scale and the Short Form 36 mental component summary. Criterion validity was investigated by performing a receiver operating characteristics curve analysis.

RESULTS

The Chinese GFI achieved semantic, idiomatic, and experiential equivalence. It had a high response rate among nursing home elders. It also showed good internal consistency (ICC = 0.712) and excellent test-retest reliability. Regarding construct validity, it presented good known-group divergent validity based on age. The correlations between the GFI domains and their corresponding measures were consistent as hypothesized, demonstrating convergent validity of the GFI. Using the Fried frailty phenotypes as reference criteria, the Chinese GFI showed satisfactory diagnostic accuracy for frailty (AUC = 0.823) and prefrailty (AUC = 0.791). The optimal cutoff point was 4 for frailty and 3 for prefrailty.

CONCLUSIONS

The GFI was successfully adapted for Chinese nursing home residents and presented acceptable validity and reliability.

AMPI-AB validity and reliability: a multidimensional tool in resource-limited primary care settings

Background

The early identification of individuals at high risk for adverse outcomes by a Comprehensive Geriatric Assessment (CGA) in resource-limited primary care settings enables tailored treatments, however, the evidence concerning its benefits are still controversial. The main objective of this study was to examine the validity and reliability of the “Multidimensional Assessment of Older People in Primary Care (AMPI-AB)”, a CGA for primary care in resource-limited settings.

Methods

Longitudinal study, with median follow-up time of 16 months. Older adults from a public primary care unit in São Paulo, Brazil, were consecutively admitted. Reliability was tested in a sample from a public geriatric outpatient clinic. Participants were classified by the AMPI-AB score as requiring a low, intermediate or high complexity of care. The Physical Frailty Phenotype was used to explore the AMPI-AB’s concurrent validity. Predictive validity was assessed with mortality, worsening of the functional status, hospitalizations, emergency room (ER) visits and falls. The area under the ROC curve and logistic regression were calculated for binary outcomes, and a Cox proportional hazards model was used for survival analysis.

Results

Older adults (n = 317) with a median age of 80 (74–86) years, 67% female, were consecutively admitted. At the follow-up, 7.1% of participants had died, and increased dependency on basic and instrumental activities of daily living was detected in 8.9 and 41.1% of the participants, respectively. The AMPI-AB score was accurate in detecting frailty (area under the ROC curve = 0.851), predicted mortality (HR = 1.25, 95%CI = 1.13–1.39) and increased dependency on basic (OR = 1.26, 95%CI = 1.10–1.46) and instrumental (OR = 1.22, 95%CI = 1.12–1.34) activities of daily living, hospitalizations (OR = 2.05, 95%CI = 1.04–1.26), ER visits (OR = 1.20, 95%CI = 1.10–1.31) and falls (OR = 1.10, 95%CI = 1.01–1.20), all models adjusted for sex and years of schooling. Reliability was tested in a sample of 52 older adults with a median age of 72 (85–64) years, 63.5% female. The AMPI-AB also had good interrater (ICC = 0.87, 95%CI = 0.78–0.92), test-retest (ICC = 0.86, 95%CI = 0.76–0.93) and proxy reliability (ICC = 0.84, 95%CI = 0.67–0.93). The Cronbach’s alpha was 0.69, and the mean AMPI-AB administration time was 05:44 ± 02:42 min.

Conclusion

The AMPI-AB is a valid and reliable tool for managing older adults in resource-limited primary care settings.

Evaluating the psychometric properties of the Arabic version of the Groningen Frailty Indicator among Lebanese elderly people

Background

The levels of frailty are anticipated to increase as a result of population aging. A valid instrument is required to detect individuals at high risk of frailty. The present research aimed to assess feasibility, reliability, and construct validity of the Arabic version of Groningen Frailty Indicator (GFI) in urban and rural populations in South Lebanon.

Methods

During 2015, a cross-sectional study, which enrolled 390 community-dwelling individuals aged 65 years and above, was conducted in urban and rural areas in Nabatieh in South Lebanon. The survey included questions on sociodemographic and health-related characteristics, GFI, and Vulnerable Elders Survey-13 (VES-13). The translation and cultural adaptation of the GFI followed a standardized protocol. After that, the psychometric properties of the scale (i.e., feasibility, reliability, and validity) were evaluated.

Results

A total of 390 elderly filled out the questionnaire, of whom 51% were women and 70% lived in rural areas. 81.3% of elderly were identified as frail. The internal consistency of the GFI scale was high for all subscales (Cronbach’s alpha > 0.70), except the social scale (0.56). The GFI yielded statistically significant scores for subgroup analysis (known-groups validity) as higher levels of frailty were seen in older people, women, those with morbidities, and those reported poor financial status. The construct validity of the scale was supported by the significant correlation with the VES-13 (r = 0.73; p = 0.001), quality of life (r = − 0.22; p = 0.001), and self-reported health status (r = − 0.66; p = 0.001).

Conclusion

This study supports the feasibility, reliability, and validity of the GFI Arabic version as a screening tool for frailty among community-dwelling elderly in South Lebanon.

Description of frail older people profiles according to four screening tools applied in primary care settings: a cross sectional analysis

Background

Regarding the health care of older populations, WHO recommends shifting from disease-driven attention models towards a personalized, integrated and continuous care aimed to the maintenance and enhancement of functional capacities. Impairments in the construct of functional intrinsic capacity have been understood as the condition of frailty or vulnerability. No consensus has been yet reached regarding which tools are the most suitable for screening this kind of patients in primary care settings. Tools based on the measurement of functional performance such as Timed up and go test (TUG), Short Physical Performance battery (SPPB), self-completed questionnaires like Tilburg Frailty Indicator (TFI) and clinical judgement, as the Gerontopole Frailty Scale (GFS) may be adequate. The objective of this work is to describe and compare characteristics of community-dwelling individuals identified as vulnerable or frail by four tools applied in primary care settings.

Methods

Cross sectional analysis developed in primary care services in two regions of Spain.

Community-dwelling independent individuals aged 70 or more willing to participate were recruited and data was collected via face-to-face interviews. Frailty was assessed by TUG, SPPB, TFI and GFST. Also socio-demographic characteristics, lifestyle habits and health status data (comorbidities, polypharmacy, self-perceived health), were collected. Multiple correspondence analysis (MCA) and cluster analysis were used to identify groups of individuals with similar characteristics.

Results

Eight hundred sixty-five individuals were recruited, 53% women, with a mean age of 78 years. Four clusters of participants emerge. Cluster 1 (N = 263) contained patients categorized as robust by most of the studied tools, whereas clusters 2 (N = 199), 3 (N = 183) and 4 (N = 220) grouped patients classified as frail or vulnerable by at least one of the tools. Significant differences were found between clusters.

Conclusions

The assessed tools identify different profiles of patients according to their theoretical construct of frailty. There is a group of patients that are identified by TUG and SPPB but not by GFS or TFI. These tools may be useful in primary care settings for the implementation of a function- driven clinical care of older patients.

Predictive Accuracy of Frailty Tools for Adverse Outcomes in a Cohort of Adults 80 Years and Older: A Decision Curve Analysis

OBJECTIVES

To compare the predictive performance of 3 frailty identification tools for mortality, hospitalization, and functional decline in adults aged ≥80 years using risk reclassification statistics and decision curve analysis.

DESIGN

Population-based, prospective cohort.

SETTING

BELFRAIL study, Belgium.

PARTICIPANTS

560 community-dwelling adults aged ≥80 years.

MEASUREMENTS

Frailty by Cardiovascular Health Study (CHS) phenotype, Longitudinal Aging Study Amsterdam (LASA) markers, and Groeningen Frailty Indicator (GFI); mortality until 5.1 ± 0.25 years from baseline and hospitalization until 3.0 ± 0.25 years; and functional status assessed by activities of daily living at baseline and after 1.7 ± 0.21 years.

RESULTS

Frailty prevalence was 7.3% by CHS phenotype, 21.6% by LASA markers, and 22% by GFI. Participants determined to be frail by each tool had a significantly higher risk for all-cause mortality and first hospitalization. For functional decline, only frail by GFI had a higher adjusted odds ratio. Harrell 's C-statistic for mortality and hospitalization and area under receiver operating characteristic curve for functional decline were similar for all tools and <0.70. Reclassification statistics showed improvement only by LASA markers for hospitalization and mortality. In decision curve analysis, all tools had higher net benefit than the 2 default strategies of "treat all" and "treat none" for mortality risk ≥20%, hospitalization risk ≥35%, and functional decline probability ≥10%, but their curves overlapped across all relevant risk thresholds for these outcomes.

CONCLUSIONS AND IMPLICATIONS

In a cohort of adults aged ≥80 years, 3 frailty tools based on different conceptualizations and assessment sources had comparable but unsatisfactory discrimination for predicting mortality, hospitalization, and functional decline. All showed clinical utility for predicting these outcomes over relevant risk thresholds, but none was significantly superior. Future research on frailty tools should include a focus on the specific group of adults aged ≥80 years, and the predictive accuracy for adverse outcomes of different tools needs a comprehensive assessment that includes decision curve analysis.

The Multidimensional Prognostic Index in general practice: One-year follow-up study

BACKGROUND

Older patients' health problems in general practice (GP) can often not be assigned to a specific disease, requiring a paradigm shift to goal-oriented, personalised care for clinical decision making.

PURPOSE

To investigate the predictive value of the comprehensive geriatric assessment (CGA)-based Multidimensional Prognostic Index (MPI) in a GP setting with respect to the main healthcare indicators during the 12 months following initial evaluation.

METHODS

One hundred twenty-five consecutive patients aged 70 years and older were enrolled in a GP and followed up to one year. All patients underwent a CGA based on which the MPI was calculated and subdivided into three risk groups (MPI-1, 0-0.33 = low risk, MPI-2, 0.34-0.66 = moderate risk and MPI-3, 0.67-1, severe risk). Grade of Care (GC), hospitalization rate, mortality, nursing home admission, use of home care services, falls, number of general practitioner contacts (GPC), of geriatric resources (GR) and geriatric syndromes (GS) during the 12 months following initial evaluation were collected.

RESULTS

The MPI was significantly associated with number of GS (P < .001), GR (P < .001), GC (P < .001) as well as with the average number of GPC per year (mean 10.4, P = .046). Interestingly, the clinical judgement of the general practitioner, in this case knowing his patients for 16 years on average, was associated with adverse outcomes to a similar extent than the prediction offered by the MPI (GP/adverse outcomes and MPI/adverse outcomes P < .001).

CONCLUSION

The MPI is strongly associated with adverse outcomes in older GP patients and strongly predicts the number of GPC up to one year after initial evaluation. Considering the feasibility and the strong clinimetric properties of the MPI, its collection should be encouraged as early as possible to disclose risk conditions, implement tailored preventive strategies and improve cost-effectiveness of healthcare resources use.

Instruments for the detection of frailty syndrome in older adults: A systematic review

Frailty is a dynamic process in which there is a reduction in the physical, psychological and/or social function associated with aging. The aim of this study was to identify instruments for the detection of frailty in older adults, characterizing their components, application scenarios, ability to identify pre-frailty and clinimetric properties evaluated. The study was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), under registration number CRD42017039318. A total of 14 electronic sources were searched to identify studies that investigated instruments for the detection of frailty or that presented the construction and/or clinimetric evaluation of the instrument, according to criteria established by the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN). 96 studies were included in the qualitative synthesis: 51 instruments for the detection of frailty were identified, with predominantly physical domains; 40 were constructed and/or validated for use in the older adult community population, 28 only highlighted the distinction between frail and non-frail individuals and 23 presented three or more levels of frailty. The FRAGIRE, FRAIL Scale, Edmonton Frail Scale and IVCF-20 instruments were the most frequently analyzed in relation to clinimetric properties. It was concluded that: (I) there is a large number of instruments for measuring the same construct, which makes it difficult for researchers and clinicians to choose the most appropriate; (II) the FRAGIRE and CFAI stand out due to their multidimensional aspects, including an environmental assessment; however, (III) the need for standardization of the scales was identified, since the use of different instruments in clinical trials may prevent the comparability of the results in systematic reviews and; (IV) considering the different instruments identified in this review, the choice of researchers/clinicians should be guided by the issues related to the translation and validation for their location and the suitability for their context.

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

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

Predictive Capacity of Frailty Phenotype Toward Patterns of Disability Identified Using Latent Class Analysis

OBJECTIVES

Frailty phenotype (FP) has low sensitivity toward the identification of older people who will lose 1 or more activities of daily living. Nevertheless, the definition of disability in terms of activities of daily living may not resemble the pattern of functional impairment occurring during aging. The aim of this study was to examine the discriminative capacity of the FP toward the identification of patterns of disabilities in an extended list of tasks, identified among community-dwelling older people.

DESIGN

Longitudinal cohort study.

SETTING AND PARTICIPANTS

We included 997 persons age 65 years and older selected from the Invecchiare in Chianti (InCHIANTI) Study population.

MEASURES

Using latent class analysis, we assessed the pattern of 3-year changes in 24 functional tasks. Then, we calculated the discriminative capacity of the FP for each pattern of disability. Analyses were stratified by sex.

RESULTS

In both men and women, we recognized 3 classes: stable function; disability in complex tasks; and global functional disability. Among women, ability of FP to identify persons in global functional disability showed sensitivity = 0.42, specificity = 0.98, positive and negative predictive values 0.75 and 0.91; the corresponding values for prediction of disability in complex tasks were 0.13, 0.98, 0.68, and 0.75. Similar results were obtained among men.

CONCLUSIONS/IMPLICATIONS

Over 3 years, older people of the InCHIANTI population remained largely functional stable, some persons developed deficiency in complex tasks, and a minority developed global functional disability. Trying to predict these 3 patterns may be useful for the care of older people in order to promote individualized interventions to reduce the burden of disabilities and their consequences. To this purpose, FP showed a fairly good capacity to identify people at risk of functional decline, but further studies are needed to identify instruments with better prognostic capacity.

Frailty, transition in frailty status and all-cause mortality in older adults of a Taichung community-based population

BACKGROUND

Previous studies have reported the associations of frailty phenotype or its components with mortality. However, studies that explored the effects of transition in frailty status on mortality were far less in Asian or Chinese. The aim of this study was to evaluate baseline frailty status and one-year change of frailty status in relation to all-cause mortality in Taiwanese community-dwelling older adults who participated in the Taichung Community Health Study for Elders.

METHODS

We conducted a community-based prospective cohort study. A total of 921 community-dwelling elderly men and women aged 65-99 years in Taichung City were enrolled in 2009-2010 and were followed up through 2016. We adopted the definition of frailty proposed by Fried et al., including five components: shrinking, weakness, poor endurance and energy, slowness, and low physical activity. Cox proportional hazards models were used to determine adjusted hazard ratios (HRs) of mortality with 95% confidence intervals (CIs) for frailty at baseline and one-year change in frailty status.

RESULTS

There were 160 deaths during the follow-up period. The mortality rates in groups of robust and frail were 20.26 and 84.66 per 1000 person-years respectively. After multivariate adjustment, the HR (CIs) for baseline frailty was 2.67 (1.73-4.12). Poor endurance and energy [1.88 (1.03-3.42)], slowness [2.60 (1.76-3.83)] and weakness [1.65 (1.16-2.33)] were found to be predictors of mortality. Increased risks in mortality for subgroups of robust-to-frail [2.76 (1.22-6.27)], frail-to-robust [3.87 (1.63, 9.19)], and frail-to-frail [4.08 (1.92-8.66)] over one-year period were observed compared with those remaining robust.

CONCLUSION

Baseline frailty status and one-year change in frailty status are associated with 6-year all-cause mortality among Taiwanese elderly adults. Frailty may be useful for identifying older adults at high risks for mortality prevention.

Current situation of frailty screening tools for older adults

Frailty is a geriatric syndrome associated with adverse outcomes such as falls, disability, and mortality. Frailty is common and contributes to rising health care costs. Early screening and timely tailored intervention may effectively prevent or delay the adverse outcomes in older adults. Studies on frailty and its specific measurement tools are increasing in number, but the debate on the screening instruments remains. Currently, self-reported screening tools can identify frailty and predict the risk of adverse outcomes in older adults. Because they are easy to use and quickly provide information, self-reported frailty screening tools have significant implication in primary care settings and clinics. We reviewed the frailty screening instruments in older adults and proposed a two-step pathway for frailty identification, and to manage declines in intrinsic capacity as well as boost resilience.

Multicomponent Frailty Assessment Tools for Older People with Psychiatric Disorders: A Systematic Review

OBJECTIVE

To review evidence evaluating the use of multicomponent frailty assessment tools in assessing frailty in older adults with psychiatric disorders.

METHODS

A systematic literature review was conducted to identify all multicomponent frailty assessment tools (ie, a tool that assesses two or more indicators of frailty). The items of each frailty assessment tool were compared with Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) diagnostic criteria for psychiatric disorders to assess construct overlap. Studies conducted in community, inpatient, and outpatient clinical settings were considered for inclusion.

PARTICIPANTS

Adults aged 60 years or older.

RESULTS

A total of 5639 records were identified following the removal of duplicates, from which 95 studies were included for review. Of the 48 multicomponent frailty assessment tools identified, no tool had been developed for, or validated in, older adult populations with a psychiatric disorder. Overall, 20 of 48 frailty assessment tools contained a psychological assessment domain, with 17 of 48 tools citing the presence of depressed mood and/or anxiety as a frailty indicator. Common areas of construct overlap in frailty assessment tools and DSM-5 diagnostic criteria included weight loss (29 of 48) and fatigue (21 of 48).

CONCLUSIONS

Significant construct overlap exists between the indicators of frailty as conceptualized in existing frailty assessment tools and DSM-5 diagnostic criteria for common psychiatric disorders including major depressive episode and generalized anxiety disorder that has the potential to confound frailty assessment results. Further research is necessary to establish a reliable and valid tool to assess frailty in this population. J Am Geriatr Soc 67:1085-1095, 2019.

Diagnostic test accuracy of self-reported frailty screening instruments in identifying community-dwelling older people at risk of frailty and pre-frailty: a systematic review protocol

REVIEW QUESTION/OBJECTIVE

The question of this systematic review is: What is the diagnostic test accuracy of self-reported frailty screening instruments among community-dwelling older people against any of the following reference standard tests: the frailty phenotype, frailty index and comprehensive geriatric assessment?

Women's health status in urban Ghana: dimensions and differentials using short form 36

BACKGROUND

Global discourse on population, health and development have placed women's health issues at the top of development agenda. Women's reproductive health has received some attention in Ghana since the mid-1990s. However, studies on women's general health status, dimensions and the differentials in a rapidly growing urban setting is poorly understood and under-researched. This study sought to examine the various pathways in which individual socio-demographic factors, economic characteristics and endowment influence self-assessed health status among women living in the city of Accra, Ghana.

METHODS

The paper draws on a cross-sectional study carried out in 2008 and 2009 using a representative sample of urban women 20 years and older (n = 2814). Multivariate stepwise linear regression models were performed to investigate the influence of socio-demographic, economic and health indicators on health-related quality of life, measured by eight sub-scales of the Short Form-36 (SF-36). Interaction effects between some demographic and socio-economic variables were also performed.

RESULTS

The analyses show diverse relationships between demographic, socio-economic and health indicators and health outcomes assessed using eight SF-36 sub-scales. Education, disease symptoms and age of the respondent were the most significant factors influencing good overall health status. Interestingly, age has no significant effect on mental health after controlling for all other explanatory variables.

CONCLUSIONS

The findings show that health issues are multi-faceted requiring socio-cultural, health and economic policy interventions. Investing in women's education is important to improve health status. There is also the need for more effective collaboration across various sectors to improve the health and well-being of women in general. Ageing has increasing relationship with poor physical health status and the elderly should be given needed attention and support.

Detecting frail, older adults and identifying their strengths: results of a mixed-methods study

Background

The debate on frailty in later life focuses primarily on deficits and their associations with adverse (health) outcomes. In addition to deficits, it may also be important to consider the abilities and resources of older adults. This study was designed to gain insights into the lived experiences of frailty among older adults to determine which strengths can balance the deficits that affect frailty.

Methods

Data from 121 potentially frail community-dwelling older adults in Flemish-speaking Region of Belgium and Brussels were collected using a mixed-methods approach. Quantitative data were collected using the Comprehensive Frailty Assessment Instrument (CFAI), Montreal Cognitive Assessment (MoCA), and numeric rating scales (NRS) for quality of life (QoL), care and support, meaning in life, and mastery. Bivariate analyses, paired samples t-tests and means were performed. Qualitative data on experiences of frailty, frailty balance, QoL, care and support, meaning in life, and mastery were collected using semi-structured interviews. Interviews were subjected to thematic content analysis.

Results

The “no to mild frailty” group had higher QoL, care and support, meaning in life, and mastery scores than the “severe frailty” group. Nevertheless, qualitative results indicate that, despite being classified as frail, many older adults experienced high levels of QoL, care and support, meaning in life, and mastery. Respondents mentioned multiple balancing factors for frailty, comprising individual-level circumstances (e.g., personality traits, coping strategies, resilience), environmental influences (e.g., caregivers, neighborhood, social participation), and macro-level features (e.g., health literacy, adequate financial compensation). Respondents also highlighted that life changes affected their frailty balance, including changes in health, finances, personal relationships, and living situation.

Conclusion

The findings indicate that frailty among older individuals can be considered as a dynamic state and, regardless of frailty, balancing factors are important in maintaining a good QoL. The study investigated not only the deficits, but also the abilities, and resources of frail, older adults. Public policymakers and healthcare organizations are encouraged to include these abilities, supplementary or even complementary to the usual focus on deficits.

A retrospective cohort study on the risk assessment of newly certificated long-term care need of elderly individuals in a community: Basic checklist and specific health checkup

Objective: This study aimed to examine the factors influencing the requirement of a certificate of long-term care using a basic checklist and items listed in the Special Health Checkup.

Method: This study included 7,820 individuals living in Uji city, who were selected from among 8,000 elderly individuals who, in 2008, underwent a specific health checkup (hereafter referred to as the ‘specific health checkup for the old-old elderly individuals’) for those aged 75 years and above. They answered questions from basic checklists at the time, and 180 individuals were excluded as they had already qualified for requiring the certificate of long-term care at the time of the checkup. The follow-up period extended from the day of the specific health checkup for the old-old elderly individuals to March 31, 2013. The data were analyzed using the certificate of needing long-term care as the response variable. The explanatory variables were the basic attributes, items listed in the specific health checkup for the old-old elderly individuals, interview sheets, and basic checklists. Cox proportional hazards regression analysis was conducted.

Results: In total, 1,280 elderly individuals qualified for requiring the certificate of needing long-term care. The risk factors for the young-old elderly individuals aged 65 to 74 years were as follows: hepatic dysfunction (hazard ratio {HR}=1.69), the presence of subjective symptoms (HR=1.41), an above-normal abdominal circumference (HR=1.36), old age (HR=1.13), a reduced frequency of going out since the previous year (HR=1.87), the use of support for standing up after being seated on a chair (HR=1.86), no deposit or withdrawals made (HR=1.84), the anxiety of falling down (HR=1.50), an inability to climb stairs without holding a railing or wall (HR=1.49), as well as an increased difficulty in eating tough food items compared with 6 months prior (HR=1.44). The risk factors for the old-old elderly individuals were as follows: a positive reaction on proteinuria (HR=1.27), anemia (HR=1.18), old age (HR=1.10), inability to travel on a bus or train by themselves (HR=1.53), the inability to climb stairs without holding a railing or wall (HR=1.48), weight loss (HR=1.36), a reduced sense of appreciation of the activities they had previously participated in, over a span of 2 weeks (HR=1.30), the use of support for standing up after being seated on a chair (HR=1.23), and the anxiety of falling down (HR=1.20).

Conclusion: The items listed in the specific medical checkup as well as the basic checklists were found to be risk factors for both the young-old elderly individuals and the old-old elderly individuals, indicating the need to utilize these lists for the prevention of nursing even in the late stages of life. Moreover, these results suggest the importance of screening elderly individuals suffering from hyperkinesis using the basic checklist and conducting preventive interventions in order to maintain and improve their physical functions.

Frailty and the Prediction of Negative Health Outcomes: A Meta-Analysis

INTRODUCTION

Frailty is one of the most important concerns regarding our aging population. Evidence grows that the syndrome is linked to several important health outcomes. A general overview of frailty concepts and a comprehensive meta-analysis of their relation with negative health outcomes still lacks in literature, making it difficult for health care professionals and researchers to recognize frailty and the related health risks on the one hand and on the other hand to appropriately follow up the frailty process and take substantiated action. Therefore, this study aims to give an overview of the predictive value of the main frailty concepts for negative health outcomes in community-dwelling older adults.

METHODS

This review and meta-analysis assembles prospective studies regarding the relation between frailty and any potential health outcome. Frailty instruments were subdivided into frailty concepts, so as to make comprehensive comparisons. Odds ratios (ORs), hazard ratios (HRs), and relative risk (RR) scores were extracted from the studies, and meta-analyses were conducted in OpenMeta Analyst software.

RESULTS

In total, 31 articles retrieved from PubMed, Web of Knowledge, and PsycInfo provided sufficient information for the systematic review and meta-analysis. Overall, (pre)frailty increased the likelihood for developing negative health outcomes; for example, premature mortality (OR 2.34 [1.77-3.09]; HR/RR 1.83 [1.68-1.98]), hospitalization (OR 1.82 [1.53-2.15]; HR/RR 1.18 [1.10-1.28]), or the development of disabilities in basic activities of daily living (OR 2.05 [1.73-2.44]); HR/RR 1.62 [1.50-1.76]).

CONCLUSION

Overall, frailty increases the risk for developing any discussed negative health outcome, with a 1.8- to 2.3-fold risk for mortality; a 1.6- to 2.0-fold risk for loss of activities of daily living; 1.2- to 1.8-fold risk for hospitalization; 1.5- to 2.6-fold risk for physical limitation; and a 1.2- to 2.8-fold risk for falls and fractures. The analyses presented in this study can be used as a guideline for the prediction of negative outcomes according to the frailty concept used, as well as to estimate the time frame within which these events can be expected to occur.

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

BACKGROUND

This study compares the performance of four frailty screening tools in predicting relevant adverse outcome (disability, institutionalization and mortality) in community-dwelling elderly.

METHODS

Our study involved a secondary analysis of data from the FréLE cohort study. We focused on the following four frailty screening tools: the abbreviated Comprehensive Geriatric Assessment (aCGA), the Groningen Frailty Indicator (GFI), the Vulnerable Elders Survey-13 (VES-13) and the Fried scale. We used the Barberger-Gateau scale to assess disability. For comparison, we determined the capacity of these tools to predict the occurrence of disability, institutionalization or death using the receiver operating characteristic (ROC) curve. We also determined the threshold at which an optimal balance between sensitivity and specificity was reached. Odds ratios (ORs) were calculated to compare the risk of adverse outcome in the frail versus non-frail groups.

RESULTS

In total, 1643 participants were included in the mortality analyses; 1224 participants were included in the analyses of the other outcomes (74.5% of the original sample). The mean age was 77.7 years, and 48.1% of the participants were women. The prevalence of frailty in this sample ranged from 15.0% (Fried) to 52.2% (VES-13). According to the Barberger-Gateau scale, 643 (52.5%) participants were fully independent; 392 (32.0%) were mildly disabled; 118 (9.6%) were moderately disabled; and 71 (5.8%) were severely disabled. The tool with the greatest sensitivity for predicting the occurrence of disability, mortality and institutionalization was VES-13, which showed sensitivities of 91.0%, 89.7% and 92.3%, respectively. The values for the area under the curve (AUC) of the four screening tools at the proposed cut-off points ranged from 0.63 to 0.75. The odds (univariate and multivariate analysis) of developing a disability were significantly greater among the elderly identified as being frail by all four tools.

CONCLUSION

The multivariate analyses showed that the VES-13 may predict the occurrence of disability, mortality and institutionalization. However, the AUC analysis showed that even this tool did not have good discriminatory ability. These findings suggest that despite the high number of frailty screening tools described in the literature, there is still a need for a screening tool with high predictive performance.

An Evaluation of the Central Nervous System Medication Use and Frailty among Residents of Aged Care Homes in Malaysia

BACKGROUND/AIMS

Old age and institutionalization in care homes are associated with increased use of risk medications affecting the central nervous system (CNS). This study evaluated medication utilization and appropriateness; and assessed frailty among residents of Malaysian aged care homes.

METHODS

The subjects of this study included 202 elderly (≥65 years) residents of 17 aged care homes in suburban peninsular Malaysia. Frailty was measured using the Groningen Frailty Indicator (GFI) score and independence in daily living was measured as KATZ activity of daily living score. Medication appropriateness was assessed using the Medication Appropriateness Index (MAI) and 2015 Beers' criteria for Potentially Inappropriate Medication (PIM).

RESULTS

CNS medications constituted about 16% of the total, with an average of 0.8 ± 1.1 medications per resident, which reduced to 0.5 ± 0.8 medications after 3 months. Frailty (154/202) and polypharmacy (90/202) were highly prevalent in study subjects. Subjects on CNS medications had significantly higher GFI score (7.1 vs. 5.9; p = 0.031), polypharmacy (57.8 vs. 35.3%; p = 0.002), number of PIMs (0.9 vs. 0.2; p = 0.001), and mean summed MAI score (3.6 vs. 2.6; p = 0.015) than subjects not on CNS medications. Medication number was also significantly correlated with GFI (r = 0.194; p = 0.006) and KATZ (r = 0.141; p = 0.046) scores.

CONCLUSION

Frailty and polypharmacy were highly prevalent among aged care home subjects taking CNS medications. These findings support the notion that periodic regular medication review should improve the overall use of medications in elderly patients.

Pathways from physical frailty to activity limitation in older people: Identifying moderators and mediators in the English Longitudinal Study of Ageing

Physical frailty increases the risk of future activity limitation, which in turn, compromises independent living of older people and limits their healthspan. Thus, we seek to identify moderators and mediators of the effect of physical frailty on activity limitation change in older people, including gender- and age-specific effects. In a longitudinal study using data from waves 2, 4, and 6 of the English Longitudinal Study of Ageing, unique physical frailty factor scores of 4638 respondents aged 65 to 89years are obtained from confirmatory factor analysis of physical frailty, which is specified by three indicators, namely slowness, weakness, and exhaustion. Using a series of autoregressive cross-lagged models, we estimate the effect of physical frailty factor score on activity limitation change, including its moderation by social conditions, and indirect effects through physical and psychological conditions. We find that the effect of physical frailty on activity limitation change is significantly stronger with older age, while it has significant indirect effects through low physical activity, depressive symptoms, and cognitive impairment. In turn, indirect effects of physical frailty through low physical activity and cognitive impairment are stronger with older age. Sensitivity analyses suggest that these effects vary in their robustness to unmeasured confounding. We conclude that low physical activity, depressive symptoms, and cognitive impairment are potentially modifiable mediators on pathways from physical frailty to activity limitation in older people, including those who are very old. This evidence offers support for population-level interventions that target these conditions, to mitigate the effect of physical frailty on activity limitation, and thereby enhance healthspan.

Screening for frailty in community-dwelling elderly subjects: Predictive validity of the modified SEGA instrument

AIMS

To study the capacity of the SEGAm instrument to predict loss of independence among elderly community-dwelling subjects.

METHODS

The study was performed in four French departments (Ardennes, Marne, Meurthe-et-Moselle, Meuse). Subjects aged 65 years or more, living at home, who could read and understand French, with a degree of autonomy corresponding to groups 5 or 6 in the AGGIR autonomy evaluation scale were included. Assessment included demographic characteristics, comprehensive geriatric assessment, and the SEGAm instrument at baseline. Subjects had follow-up visits at home at 6 and 12 months. During follow-up, vital status and level of independence were recorded. Logistic regression was used to study predictive validity of the SEGAm instrument.

RESULTS

Among the 116 subjects with complete follow-up, 84 (72.4%) were classed as not very frail at baseline, 23 (19.8%) as frail, and 9 (7.8%) as very frail; 63 (54.3%) suffered loss of at least one ADL or IADL at 12 months. By multivariable analysis, frailty status at baseline was significantly associated with loss of independence during the 12 months of follow-up (OR=4.52, 95% CI=1.40-14.68; p=0.01). We previously validated the SEGAm instrument in terms of feasibility, acceptability, internal structure validity, reliability, and discriminant validity.

CONCLUSIONS

This instrument appears to be a suitable tool for screening frailty among community-dwelling elderly subjects, and could be used as a basis to plan early targeted interventions for subjects at risk of adverse outcome.

Validity of Total Kihon Checklist Score for Predicting the Incidence of 3-Year Dependency and Mortality in a Community-Dwelling Older Population

OBJECTIVES

To validate the ability of the total Kihon checklist (t-KCL) score to predict the incidence of dependency or death within 3 years in a community-dwelling older population.

DESIGN

Population-based longitudinal observational study.

SETTING

Town of Higashi-ura, Japan.

PARTICIPANTS

A total of 5542 independent seniors who were residents in the town of Higashi-ura.

MEASUREMENTS

The KCL questionnaire was sent to independent older residents. Based on our previous report, those with a t-KCL score of 0-3 were classified as robust, 4-7 as pre-frail, and 8 + as frail. The incidence of dependency or death was observed over 3 years. Dependency was defined as a new certification for long-term care insurance (LTCI) service need. Information regarding LTCI certification or death was obtained from the municipal government.

RESULTS

Of 8091 independent older adults, 5542 seniors completed the KCL questionnaire. Based on the t-KCL score, they were classified into 3 groups: 2962 (53.4%) as robust, 1625 (29.3%) as pre-frail, and 955 (17.2%) as frail. Over the 3 years, 510 seniors (9.2%) had new LTCI certifications and 170 (3.1%) died. Cox regression analysis adjusted for age and sex showed that the classification of frailty status by t-KCL score was significantly associated with the incidence of dependency both in the pre-frail and the frail [hazard ratios (HRs): 2.027 and 4.768; 95% confidence intervals (CIs): 1.575-2.608 and 3.733-6.089, respectively]. On the other hand, the ability to predict death was significant, but only in the frail group (HR: 2.830; 95% CI: 1.952-4.104).

CONCLUSION

The classification of frailty status by t-KCL score could be a significant tool to predict the incidences of dependency and mortality in older adults.

External validation of the Vulnerable Elder's Survey for predicting mortality and emergency admission in older community-dwelling people: a prospective cohort study

Background

Prospective external validation of the Vulnerable Elder’s Survey (VES-13) in primary care remains limited. The aim of this study is to externally validate the VES-13 in predicting mortality and emergency admission in older community-dwelling adults.

Methods

Design: Prospective cohort study with 2 years follow-up (2010–2012). Setting: 15 General Practices (GPs) in the Republic of Ireland. Participants: n = 862, aged ≥70 years, community-dwellers Exposure: VES-13 calculated at baseline, where a score of ≥3 denoted high risk. Outcomes: i) Mortality; ii) ≥1 Emergency admission and ≥1 ambulatory care sensitive (ACS) admission over 2 years. Statistical analysis: Descriptive statistics, model discrimination (c-statistic) and sensitivity/specificity.

Results

Of 862 study participants, a total of 246 (38%) were classified as vulnerable at baseline. Fifty-three (6%) died during follow-up and 246 (29%) had an emergency admission. At the VES-13 cut-point of ≥3 denoting high-risk model discrimination was poor for mortality (c-statistic: 0.61 (95% CI 0.54, 0.67), ≥1 emergency admission (c-statistic: 0.59 (95% CI 0.56, 0.63) and ≥1 ACS emergency admission (c-statistic: 0.63 (95% CI 0.60, 0.67).

Conclusions

In this study the VES-13 demonstrated relatively limited predictive accuracy in predicting mortality and emergency admission. External validation studies examining the tool in different health settings and healthier populations are needed and represent an interesting area for future research.

Electronic supplementary material

The online version of this article (doi:10.1186/s12877-017-0460-1) contains supplementary material, which is available to authorized users.

Cognitive Frailty in Italian Community-Dwelling Older Adults: Prevalence Rate and Its Association with Disability

Cognitive frailty is the simultaneous clinical manifestation of both physical frailty and cognitive impairment. This paper aimed to propose and test an operational definition of cognitive frailty. The following specific aims were pursued: (i) to rate the prevalence of cognitive frailty; (ii) to evaluate differences in cognitive functioning among robust, pre-frail, and frail individuals; (iii) to examine the association of cognitive frailty with disability, in a sample of Italian community-dwelling older adults. Five hundred and ninety-four older adults (mean age 73.6 years, SD=5.8) were involved in this cross-sectional study. Cognitive frailty was operationalized using the Mini Mental State Examination (cut-off score equal or less than 25) for the evaluation of cognitive functions and the five criteria of the Cardiovascular Health Study (cut-off score equal or higher than 3) for the evaluation of physical frailty. Participants positive for both instruments were classified as cognitively frail. The outcome was disability measured with the Groningen Activity Restriction Scale. Descriptive statistics, one-way and two-way analysis of covariance (ANCOVA) were carried out. The prevalence rate of cognitive frailty was 4.4%. The one-way ANCOVA, controlling for age and gender, showed a significant difference (p< .001) among robust, pre-frail, and frail participants for the cognitive functioning. Moreover, cognitively frail individuals showed a difference (p<.001) in disability in comparison with non-frail participants. Our results are significant and provide empirical evidence about the usefulness of the cognitive frailty concept.

The creation of age-friendly environments is especially important to frail older people

The preference of older people when it comes to ageing in place may be modified by levels of frailty. The aim of this research is to characterise the relationship between frailty and ageing in place, and to identify differences in neighbourhood characteristics supporting ageing in place missed by frail and non-frail older people. A concurrent nested mixed-methods approach was used. For quantitative evaluation, a sample of 945 independently living older adults residing in four districts of Rotterdam were asked to complete a questionnaire in 2013 (response rate = 62%; N = 558). In addition, 32 interviews were conducted with frail and non-frail older people. Results showed that gender, age and especially frailty were related to missed neighbourhood characteristics. People displayed awareness of their increasing frailty and often acknowledged that it increased the need for neighbourhood characteristics enabling them to age in place. We can conclude that dependence on neighbourhoods varies with frailty status. This relationship is dynamic; with frailty, older people become more dependent on their neighbourhood. However, expectations regarding neighbourhood characteristics seem to dissipate with advanced age and increasing frailty.

External validation of the Probability of repeated admission (Pra) risk prediction tool in older community-dwelling people attending general practice: a prospective cohort study

OBJECTIVES

Emergency admission is associated with the potential for adverse events in older people and risk prediction models are available to identify those at highest risk of admission. The aim of this study was to externally validate and compare the performance of the Probability of repeated admission (Pra) risk model and a modified version (incorporating a multimorbidity measure) in predicting emergency admission in older community-dwelling people.

SETTING

15 general practices (GPs) in the Republic of Ireland.

PARTICIPANTS

n=862, ≥70 years, community-dwelling people prospectively followed up for 2 years (2010-2012).

EXPOSURE

Pra risk model (original and modified) calculated for baseline year where ≥0.5 denoted high risk (patient questionnaire, GP medical record review) of future emergency admission.

PRIMARY OUTCOME

Emergency admission over 1 year (GP medical record review).

STATISTICAL ANALYSIS

descriptive statistics, model discrimination (c-statistic) and calibration (Hosmer-Lemeshow statistic).

RESULTS

Of 862 patients, a total of 154 (18%) had ≥1 emergency admission(s) in the follow-up year. 63 patients (7%) were classified as high risk by the original Pra and of these 26 (41%) were admitted. The modified Pra classified 391 (45%) patients as high risk and 103 (26%) were subsequently admitted. Both models demonstrated only poor discrimination (original Pra: c-statistic 0.65 (95% CI 0.61 to 0.70); modified Pra: c-statistic 0.67 (95% CI 0.62 to 0.72)). When categorised according to risk-category model, specificity was highest for the original Pra at cut-point of ≥0.5 denoting high risk (95%), and for the modified Pra at cut-point of ≥0.7 (95%). Both models overestimated the number of admissions across all risk strata.

CONCLUSIONS

While the original Pra model demonstrated poor discrimination, model specificity was high and a small number of patients identified as high risk. Future validation studies should examine higher cut-points denoting high risk for the modified Pra, which has practical advantages in terms of application in GP. The original Pra tool may have a role in identifying higher-risk community-dwelling older people for inclusion in future trials aiming to reduce emergency admissions.