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1.  A Frailty Instrument for primary care: findings from the Survey of Health, Ageing and Retirement in Europe (SHARE) 
BMC Geriatrics  2010;10:57.
A frailty paradigm would be useful in primary care to identify older people at risk, but appropriate metrics at that level are lacking. We created and validated a simple instrument for frailty screening in Europeans aged ≥50. Our study is based on the first wave of the Survey of Health, Ageing and Retirement in Europe (SHARE,, a large population-based survey conducted in 2004-2005 in twelve European countries.
Subjects: SHARE Wave 1 respondents (17,304 females and 13,811 males). Measures: five SHARE variables approximating Fried's frailty definition. Analyses (for each gender): 1) estimation of a discreet factor (DFactor) model based on the frailty variables using LatentGOLD®. A single DFactor with three ordered levels or latent classes (i.e. non-frail, pre-frail and frail) was modelled; 2) the latent classes were characterised against a biopsychosocial range of Wave 1 variables; 3) the prospective mortality risk (unadjusted and age-adjusted) for each frailty class was established on those subjects with known mortality status at Wave 2 (2007-2008) (11,384 females and 9,163 males); 4) two web-based calculators were created for easy retrieval of a subject's frailty class given any five measurements.
Females: the DFactor model included 15,578 cases (standard R2 = 0.61). All five frailty indicators discriminated well (p < 0.001) between the three classes: non-frail (N = 10,420; 66.9%), pre-frail (N = 4,025; 25.8%), and frail (N = 1,133; 7.3%). Relative to the non-frail class, the age-adjusted Odds Ratio (with 95% Confidence Interval) for mortality at Wave 2 was 2.1 (1.4 - 3.0) in the pre-frail and 4.8 (3.1 - 7.4) in the frail. Males: 12,783 cases (standard R2 = 0.61, all frailty indicators had p < 0.001): non-frail (N = 10,517; 82.3%), pre-frail (N = 1,871; 14.6%), and frail (N = 395; 3.1%); age-adjusted OR (95% CI) for mortality: 3.0 (2.3 - 4.0) in the pre-frail, 6.9 (4.7 - 10.2) in the frail.
The SHARE Frailty Instrument has sufficient construct and predictive validity, and is readily and freely accessible via web calculators. To our knowledge, SHARE-FI represents the first European research effort towards a common frailty language at the community level.
PMCID: PMC2939541  PMID: 20731877
2.  Are depression and frailty overlapping syndromes in mid- and late-life? A latent variable analysis 
Depression and frailty both predict disability and morbidity in later life. However, it is unclear to what extent these common geriatric syndromes represent overlapping constructs.
To examine the joint relationship between the constructs of depression and frailty.
Data come from 2004/5 wave of the Baltimore Epidemiologic Catchment Area Study and analysis is limited to participants aged 40 and older with complete data on frailty and depression indicators (N = 683). Depression was measured using the Diagnostic Interview Schedule and frailty was indexed by modified Fried criteria. A series of confirmatory latent class analyses (LCA) were used to assess the degree to which depression and frailty syndromes identify the same populations. A latent Kappa coefficient (Кl) was also estimated between the constructs.
Confirmatory LCA indicated that depression and frailty represent distinct syndromes rather than a single construct. The joint modeling of the two constructs supported a three class solution for depression and two class solution for frailty, with 2.9% categorized as severe depression, 19.4% as mild depression, and 77.7% as not depressed, and 21.1% categorized as frail and 78.9% as not frail. The chance-corrected agreement statistic indicated moderate correspondence between the depression and frailty constructs (Кl: 66, 95% CI: 0.58 – 0.74).
Results suggest that depression and frailty are interrelated concepts, yet their operational criteria identify substantively overlapping subpopulations. These findings have implications for understanding factors that contribute to the etiology and prognosis of depression and frailty in later life.
PMCID: PMC3424389  PMID: 23567406
depression; frailty; latent class analysis; aging
3.  Oral health conditions and frailty in Mexican community-dwelling elderly: a cross sectional analysis 
BMC Public Health  2012;12:773.
Oral health is an important component of general well-being for the elderly. Oral health-related problems include loss of teeth, nonfunctional removable dental prostheses, lesions of the oral mucosa, periodontitis, and root caries. They affect food selection, speaking ability, mastication, social relations, and quality of life. Frailty is a geriatric syndrome that confers vulnerability to negative health-related outcomes. The association between oral health and frailty has not been explored thoroughly. This study sought to identify associations between the presence of some oral health conditions, and frailty status among Mexican community-dwelling elderly.
Analysis of baseline data of the Mexican Study of Nutritional and Psychosocial Markers of Frailty, a cohort study carried out in a representative sample of people aged 70 and older residing in one district of Mexico City. Frailty was defined as the presence of three or more of the following five components: weight loss, exhaustion, slowness, weakness, and low physical activity. Oral health variables included self-perception of oral health compared with others of the same age; utilization of dental services during the last year, number of teeth, dental condition (edentate, partially edentate, or completely dentate), utilization and functionality of removable partial or complete dentures, severe periodontitis, self-reported chewing problems and xerostomia. Covariates included were gender, age, years of education, cognitive performance, smoking status, recent falls, hospitalization, number of drugs, and comorbidity. The association between frailty and dental variables was determined performing a multivariate logistic regression analysis. Final models were adjusted by socio-demographic and health factors
Of the 838 participants examined, 699 had the information needed to establish the criteria for diagnosis of frailty. Those who had a higher probability of being frail included women (OR = 1.9), those who reported myocardial infarction (OR = 3.8), urinary incontinence (OR = 2.7), those who rated their oral health worse than others (OR = 3.2), and those who did not use dental services (OR = 2.1). For each additional year of age and each additional drug consumed, the probability of being frail increased 10% and 30%, respectively.
Utilization of dental services and self-perception of oral health were associated with a higher probability of being frail.
PMCID: PMC3490998  PMID: 22971075
Elderly; Oral health; Frailty syndrome; Utilization of dental services
4.  Social Support, Stressors, and Frailty Among Older Mexican American Adults 
There is little research on the effects of stressors and social support on frailty. Older Mexican Americans, in particular, are at higher risk of medical conditions, such as diabetes, that could contribute to frailty. Given that the Mexican American population is rapidly growing in the United States, it is important to determine whether there are modifiable social factors related to frailty in this older group.
To address the influence of social support and stressors on frailty among older Mexican Americans, we utilized five waves of the Hispanic Established Populations for the Epidemiologic Study of the Elderly (Hispanic EPESE) to examine the impact of stressors and social support on frailty over a 12-year period. Using a modified version of the Fried and Walston Frailty Index, we estimated the effects of social support and stressors on frailty over time using trajectory modeling (SAS 9.2, PROC TRAJ).
We first grouped respondents according to one of three trajectories: low, progressive moderate, and progressive high frailty. Second, we found that the effects of stressors and social support on frailty varied by trajectory and by type of stressor. Health-related stressors and financial strain were related to increases in frailty over time, whereas social support was related to less-steep increases in frailty.
Frailty has been hypothesized to reflect age-related physiological vulnerability to stressors, and the analyses presented indicate partial support for this hypothesis in an older sample of Mexican Americans. Future research needs to incorporate measures of stressors and social support in examining those who become frail, especially in minority populations.
PMCID: PMC3478725  PMID: 23009957
Functional health status; Minority aging (race/ethnicity); Social support; Stress
5.  Transitions in Frailty Status in Older Adults in Relation to Mobility: A Multi-State Modeling Approach Employing a Deficit Count 
To investigate how changes in frailty status and mortality risk relate to baseline frailty state, mobility performance, age and sex.
The Yale Precipitating Events Project, a cohort study based in New Haven CT.
754 community-dwelling people, aged 70+ years at baseline followed-up at 18, 36 and 54 months.
Frailty status, assessed at 18-month intervals, was defined by a frailty index, as the number of deficits in 36 health variables. Mobility was defined as the time in seconds on the rapid gait test, where participants walked back and forth over a 20-ft course as quickly as possible. Multi-state transition probabilities were calculated with baseline frailty, mobility, age and sex estimated by Poisson and logistic regressions in survivors and those who died, respectively.
In multivariable analyses, baseline frailty status and age were significantly associated with changes in frailty status and the risk of death, while mobility was significantly associated with the former, but not with mortality. At all values of the frailty index, compared to those with poor mobility, participants with better mobility were more likely to remain stable or to improve. For example, at 54 months, 20.6% (95% confidence interval (CI) =16–25.2) of participants with poor mobility had the same or fewer deficits compared to 32.4% (95% CI=27.9–36.9) of those with better mobility.
A multi-state transition model effectively measured the probability of changes in frailty status and in the risk of death. Mobility, age and baseline frailty were significant factors in frailty state transitions.
PMCID: PMC3125634  PMID: 21391943
frailty; Frailty Index; mortality; aging; mobility; multistate model
6.  Social Vulnerability, Frailty and Mortality in Elderly People 
PLoS ONE  2008;3(5):e2232.
Social vulnerability is related to the health of elderly people, but its measurement and relationship to frailty are controversial. The aims of the present study were to operationalize social vulnerability according to a deficit accumulation approach, to compare social vulnerability and frailty, and to study social vulnerability in relation to mortality.
Methods and Findings
This is a secondary analysis of community-dwelling elderly people in two cohort studies, the Canadian Study of Health and Aging (CSHA, 1996/7–2001/2; N = 3707) and the National Population Health Survey (NPHS, 1994–2002; N = 2648). Social vulnerability index measures that used self-reported items (23 in NPHS, 40 in CSHA) were constructed. Each measure ranges from 0 (no vulnerability) to 1 (maximum vulnerability). The primary outcome measure was mortality over five (CHSA) or eight (NPHS) years. Associations with age, sex, and frailty (as measured by an analogously constructed frailty index) were also studied. All individuals had some degree of social vulnerability. Women had higher social vulnerability than men, and vulnerability increased with age. Frailty and social vulnerability were moderately correlated. Adjusting for age, sex, and frailty, each additional social ‘deficit’ was associated with an increased odds of mortality (5 years in CSHA, odds ratio = 1.05, 95% confidence interval: 1.02–1.07; 8 years in the NPHS, odds ratio = 1.08, 95% confidence interval: 1.03–1.14). We identified a meaningful survival gradient across quartiles of social vulnerability, and although women had better survival than men, survival for women with high social vulnerability was equivalent to that of men with low vulnerability.
Social vulnerability is reproducibly related to individual frailty/fitness, but distinct from it. Greater social vulnerability is associated with mortality in older adults. Further study on the measurement and operationalization of social vulnerability, and of its relationships to other important health outcomes, is warranted.
PMCID: PMC2375054  PMID: 18493324
7.  Comparing frailty measures in their ability to predict adverse outcome among older residents of assisted living 
BMC Geriatrics  2012;12:56.
Few studies have directly compared the competing approaches to identifying frailty in more vulnerable older populations. We examined the ability of two versions of a frailty index (43 vs. 83 items), the Cardiovascular Health Study (CHS) frailty criteria, and the CHESS scale to accurately predict the occurrence of three outcomes among Assisted Living (AL) residents followed over one year.
The three frailty measures and the CHESS scale were derived from assessment items completed among 1,066 AL residents (aged 65+) participating in the Alberta Continuing Care Epidemiological Studies (ACCES). Adjusted risks of one-year mortality, hospitalization and long-term care placement were estimated for those categorized as frail or pre-frail compared with non-frail (or at high/intermediate vs. low risk on CHESS). The area under the ROC curve (AUC) was calculated for select models to assess the predictive accuracy of the different frailty measures and CHESS scale in relation to the three outcomes examined.
Frail subjects defined by the three approaches and those at high risk for decline on CHESS showed a statistically significant increased risk for death and long-term care placement compared with those categorized as either not frail or at low risk for decline. The risk estimates for hospitalization associated with the frailty measures and CHESS were generally weaker with one of the frailty indices (43 items) showing no significant association. For death and long-term care placement, the addition of frailty (however derived) or CHESS significantly improved on the AUC obtained with a model including only age, sex and co-morbidity, though the magnitude of improvement was sometimes small. The different frailty/risk models did not differ significantly from each other in predicting mortality or hospitalization; however, one of the frailty indices (83 items) showed significantly better performance over the other measures in predicting long-term care placement.
Using different approaches, varying degrees of frailty were detected within the AL population. The various approaches to defining frailty were generally more similar than dissimilar with regard to predictive accuracy with some exceptions. The clinical implications and opportunities of detecting frailty in more vulnerable older adults require further investigation.
PMCID: PMC3573890  PMID: 22978265
Frailty; Predictive accuracy; Agreement; Assisted living
8.  Frailty, HIV Infection, and Mortality in an Aging Cohort of Injection Drug Users 
PLoS ONE  2013;8(1):e54910.
Frailty is associated with morbidity and premature mortality among elderly HIV-uninfected adults, but the determinants and consequences of frailty in HIV-infected populations remain unclear. We evaluated the correlates of frailty, and the impact of frailty on mortality in a cohort of aging injection drug users (IDUs).
Frailty was assessed using standard criteria among HIV-infected and uninfected IDUs in 6-month intervals from 2005 to 2008. Generalized linear mixed-model analyses assessed correlates of frailty. Cox proportional hazards models estimated risk for all-cause mortality.
Of 1230 participants at baseline, the median age was 48 years and 29% were HIV-infected; the frailty prevalence was 12.3%. In multivariable analysis of 3,365 frailty measures, HIV-infected IDUs had an increased likelihood of frailty (OR, 1.66; 95% CI, 1.24–2.21) compared to HIV-uninfected IDUs; the association was strongest (OR, 2.37; 95% CI, 1.62–3.48) among HIV-infected IDUs with advanced HIV disease (CD4<350 cells/mm3 and detectable HIV RNA). No significant association was seen with less advanced disease. Sociodemographic factors, comorbidity, depressive symptoms, and prescription drug abuse were also independently associated with frailty. Mortality risk was increased with frailty alone (HR 2.63, 95% CI, 1.23–5.66), HIV infection alone (HR 3.29, 95% CI, 1.85–5.88), and being both HIV-infected and frail (HR, 7.06; 95%CI 3.49–14.3).
Frailty was strongly associated with advanced HIV disease, but IDUs with well-controlled HIV had a similar prevalence to HIV-uninfected IDUs. Frailty was independently associated with mortality, with a marked increase in mortality risk for IDUs with both frailty and HIV infection.
PMCID: PMC3561408  PMID: 23382997
9.  Frailty and Its Impact on Health-Related Quality of Life: A Cross-Sectional Study on Elder Community-Dwelling Preventive Health Service Users 
PLoS ONE  2012;7(5):e38079.
The purpose of this study was to identify the incidence of frailty and to investigate the relationship between frailty status and health-related quality of life (HRQoL) in the community-dwelling elderly population who utilize preventive health services.
People aged 65 years and older who visited a medical center in Taipei City from March to August in 2011 for an annual routine check-up provided by the National Health Insurance were eligible. A total of 374 eligible elderly adults without cognitive impairment had a mean age of 74.6±6.3 years. Frailty status was determined according to the Fried frailty criteria. HRQoL was measured with Short Form-36 (SF-36). Multiple regression analyses examined the relationship between frailty status and the two summary scales of SF-36. Models were adjusted for the participants' sociodemographic and health status.
After adjusting for sociodemographic and health-related covariables, frailty was found to be more significantly associated (p<0.001) with lower scores on both physical and mental health-related quality of life summary scales compared with robustness. For the frailty phenotypes, slowness represented the major contributing factor in the physical component scale of SF-36, and exhaustion was the primary contributing factor in the mental component scale.
The status of frailty is closely associated with HRQoL in elderly Taiwanese preventive health service users. The impacts of frailty phenotypes on physical and mental aspects of HRQoL differ.
PMCID: PMC3360631  PMID: 22662268
10.  Reduced Health-Related Quality of Life in Elders with Frailty: A Cross-Sectional Study of Community-Dwelling Elders in Taiwan 
PLoS ONE  2011;6(7):e21841.
Exploring the domains and degrees of health-related quality of life (HRQOL) that are affected by the frailty of elders will help clinicians understand the impact of frailty. This association has not been investigated in community-dwelling elders. Therefore, we examined the domains and degree of HRQOL of elders with frailty in the community in Taiwan.
A total of 933 subjects aged 65 years and over were recruited in 2009 from a metropolitan city in Taiwan. Using an adoption of the Fried criteria, frailty was defined by five components: shrinking, weakness, poor endurance and energy, slowness, and low physical activity level. HRQOL was assessed by the short form 36 (SF-36). The multiple linear regression model was used to test the independent effects of frailty on HRQOL.
After multivariate adjustment, elders without frailty reported significantly better health than did the pre-frail and frail elders on all scales, and the pre-frail elders reported better health than did the frail elders for all scales except the scales of role limitation due to physical and emotional problems and the Mental Component Summary (MCS). The significantly negative differences between frail and robust elders ranged from 3.58 points for the MCS to 22.92 points for the physical functioning scale. The magnitude of the effects of frail components was largest for poor endurance and energy, and next was for slowness. The percentages of the variations of these 10 scales explained by all factors in the models ranged from 11.1% (scale of role limitation due to emotional problems) to 49.1% (scale of bodily pain).
Our study demonstrates that the disabilities in physical health inherent in frailty are linked to a reduction in HRQOL. Such an association between clinical measures and a generic measure of the HRQOL may offer clinicians new information to understand frailty and to conceptualize it within the broader context of disability.
PMCID: PMC3128625  PMID: 21747961
11.  The Hatoyama Cohort Study: Design and Profile of Participants at Baseline 
Journal of Epidemiology  2012;22(6):551-558.
Investigation of frailty among elderly adults and development of prevention strategies to address this are critical in delaying progression of functional decline and thus extending healthy life expectancy. However, there has been no Japanese epidemiologic cohort study of frailty. The Hatoyama Cohort Study was launched in 2010 to identify factors that predict functional decline and to establish strategies to prevent frailty among community-dwelling elderly Japanese. This report describes the study design and the profile of the participants at baseline.
The Hatoyama Cohort Study is a prospective study of community-dwelling individuals aged 65 years or older living in the town of Hatoyama in Saitama Prefecture, Japan. Comprehensive information, including socioeconomic status, physiological indicators, physical, psychological, and cognitive function, social capital, neighborhood environment, and frailty, was collected in a baseline survey using face-to-face interviews in September 2010. Survival time, long-term care insurance certification, and medical and long-term care costs after the baseline survey will be followed. In addition, a follow-up survey will be conducted in the same manner as the baseline survey every 2 years.
A total of 742 people participated in the baseline survey (mean age: 71.9 ± 5.2 years, men: 57.7%, living alone: 7.7%). Almost all participants were independent in their daily lives, and approximately 10% were categorized as frail on the kaigo-yobo (care prevention) checklist.
The Hatoyama Cohort Study is expected to contribute to the development of strategies that prevent frailty in later life and extend healthy life expectancy in Japan’s rapidly aging society.
PMCID: PMC3798568  PMID: 23117221
cohort profile; community-dwelling elderly; frailty; functional decline; Hatoyama Cohort Study
12.  A comparison of Dutch frail older adults in 1998 and 2008: prevalences and determinants 
Society is facing a growing number of older people. With the increase of older people an increase in number of frail persons is expected. But will the increase in number of frail persons parallel the increase of the number of older adults? Or are the features of older adults changing in time and are these changes reducing or amplifying the increase of frail older adults?
To present the differences in prevalence of frail older persons in 1998 and in 2008 and the influence of socio-demographic and health features on the difference between these two cohorts.
The data were collected in the context of the Longitudinal Aging Study Amsterdam (LASA). For this particular study we selected community dwelling respondents aged 65–88 years who had complete data in 1995 or 2008. Frailty was composed out of seven markers: BMI, cognitive functioning, grip strength, tiredness, vision and hearing problems and physical activity. Two cohorts, 1998 and 2008, were compared and the relative numbers of frail older adults in both cohorts were calculated. Next the association of different socio-demographic and health features with frailty was examined.
Preliminary results show a decrease in the prevalence of frail older adults from 18.5% in 1998 to 9.9% in 2008. The prevalence of frail people in 2008 for all age groups decreased compared to 1995 but in particular for the youngest age groups. In addition, the decrease in frail women is more amplified than in men. For all the markers used in defining frailty an improvement is seen for the population in 2008. Multivariate analyses will show in what degree cohort differences in frailty are related to cohort differences in education, income, co-morbidity, partner status, social network, mastery, alcohol use and smoking.
The prevalence of frail elderly in 2008 has declined compared to 1998. This can be explained by improvements in all markers of frailty. Analyses (yet to be completed) will show the influence of socio-demographic and health features.
PMCID: PMC3617773
frail older persons; prevalence; influence of socio-demographic and health features; markers
13.  Frailty among rural elderly adults 
BMC Geriatrics  2014;14:2.
This study aimed to estimate the prevalence and associated factors related to frailty, by Fried criteria, in the elderly population in a rural area in the Andes Mountains, and to analyze the relationship of these with comorbidity and disability.
A cross-sectional study was undertaken involving 1878 participants 60 years of age and older. The frailty syndrome was diagnosed based on the Fried criteria (weakness, low speed, low physical activity, exhaustion, and weight loss). Variables were grouped as theoretical domains and, along with other potential confounders, were placed into five categories: (a) demographic and socioeconomic status, (b) health status, (c) self-reported functional status, (d) physical performance-based measures, and (e) psychosocial factors. Chi-square, ANOVA, and multinomial logistic regression analyses were used to test the prognostic value of frailty for the outcomes of interest.
The prevalence of frailty was 12.2%. Factors associated with frailty were age, gender, health status variables that included self-perceived health and number of chronic conditions, functional covariate variables that included disability in activities in daily living (ADL), disabilities in instrumental ADL, chair stand time, and psychosocial variables that included depressive symptoms and cognitive impairment. Higher comorbidity and disability was found in frail elderly people. Only a subset of frail elderly people (10%) reported no disease or disability.
A relevant number of elderly persons living in rural areas in the Andes Mountains are frail. The prevalence of frailty is similar to that reported in other populations in the Latin American region. Our results support the use of modified Cardiovascular Health Study criteria to measure frailty in communities other than urban settings. Frailty in this study was strongly associated with comorbidities, and frailty and comorbidity predicted disability.
PMCID: PMC3898393  PMID: 24405584
Frailty; Disability; Prevalence; Colombia
14.  Screening for markers of frailty and perceived risk of adverse outcomes using the Risk Instrument for Screening in the Community (RISC) 
BMC Geriatrics  2014;14(1):104.
Functional decline and frailty are common in community dwelling older adults, increasing the risk of adverse outcomes. Given this, we investigated the prevalence of frailty-associated risk factors and their distribution according to the severity of perceived risk in a cohort of community dwelling older adults, using the Risk Instrument for Screening in the Community (RISC).
A cohort of 803 community dwelling older adults were scored for frailty by their public health nurse (PHN) using the Clinical Frailty Scale (CFS) and for risk of three adverse outcomes: i) institutionalisation, ii) hospitalisation and iii) death, within the next year, from one (lowest) to five (highest) using the RISC. Prior to scoring, PHNs stated whether they regarded patients as frail.
The median age of patients was 80 years (interquartile range 10), of whom 64% were female and 47.4% were living alone. The median Abbreviated Mental Test Score (AMTS) was 10 (0) and Barthel Index was 18/20 (6). PHNs regarded 42% of patients as frail, while the CFS categorized 54% (scoring ≥5) as frail. Dividing patients into low-risk (score one or two), medium-risk (score three) and high-risk (score four or five) using the RISC showed that 4.3% were considered high risk of institutionalization, 14.5% for hospitalization, and 2.7% for death, within one year of the assessment. There were significant differences in median CFS (4/9 versus 6/9 versus 6/9, p < 0.001), Barthel Index (18/20 versus 11/20 versus 14/20, p < 0.001) and mean AMTS scores (9.51 versus 7.57 versus 7.00, p < 0.001) between those considered low, medium and high risk of institutionalisation respectively. Differences were also statistically significant for hospitalisation and death. Age, gender and living alone were inconsistently associated with perceived risk. Frailty most closely correlated with functional impairment, r = −0.80, p < 0.001.
The majority of patients in this community sample were perceived to be low risk for adverse outcomes. Frailty, cognitive impairment and functional status were markers of perceived risk. Age, gender and social isolation were not and may not be useful indicators when triaging community dwellers. The RISC now requires validation against adverse outcomes.
PMCID: PMC4177708  PMID: 25238874
Screening; Frailty; Risk; Adverse outcomes; Clinical frailty scale (CFS); Risk instrument for screening in the community (RISC); Public health nurses (PHNs); Comorbidities; Cognitive impairment; Barthel index (BI); Abbreviated mental test score (AMTS)
15.  The impact of frailty on oral care behavior of older people: a qualitative study 
BMC Oral Health  2013;13:61.
Frailty has been demonstrated to negatively influence dental service-use and oral self-care behavior of older people. The aim of this study was to explore how the type and level of frailty affect the dental service-use and oral self-care behavior of frail older people.
We conducted a qualitative study through 51 open interviews with elders of varying frailty in the East-Netherlands, and used a thematic analysis to code transcripts, discussions and reviews of the attributes and meaning of the themes to the point of consensus among the researchers.
Three major themes and five sub-themes emerged from our analyses. The major themes indicate that frail elders: A) favor long-established oral hygiene routines to sustain a sense of self-worth; B) discontinue oral hygiene routines when burdened by severe health complaints, in particular chronic pain, low morale and low energy; and C) experience psychological and social barriers to oral health care when institutionalized. The subthemes associated with the discontinuation of oral care suggest that the elders accept more oral pain or discomfort because they: B1) lack belief in the results of dental visits and tooth cleaning; B2) trivialize oral health and oral care in the general context of their impaired health and old age; and B3) consciously use their sparse energy for priorities other than oral healthcare. Institutionalized elderly often discontinue oral care because of C1) disorientation and C2) inconveniencing social supports.
The level and type of frailty influences people’s perspectives on oral health and related behaviors. Frail elders associate oral hygiene with self-worth, but readily abandon visits to a dentist unless they feel that a dentist can relieve specific problems. When interpreted according to the Motivational Theory of Life Span Development, discontinuation of oral care by frail elderly could be viewed as a manifestation of adaptive development. Simple measures aimed at recognizing indicators for poor oral care behavior, and providing appropriate information and support, are discussed.
PMCID: PMC3819177  PMID: 24175989
Aged; Oral health; Frailty; Oral hygiene; Dental care; Dental health services; Self-worth; Health behavior; Toothbrushing
16.  Predicting ADL disability in community-dwelling elderly people using physical frailty indicators: a systematic review 
BMC Geriatrics  2011;11:33.
Disability in Activities of Daily Living (ADL) is an adverse outcome of frailty that places a burden on frail elderly people, care providers and the care system. Knowing which physical frailty indicators predict ADL disability is useful in identifying elderly people who might benefit from an intervention that prevents disability or increases functioning in daily life. The objective of this study was to systematically review the literature on the predictive value of physical frailty indicators on ADL disability in community-dwelling elderly people.
A systematic search was performed in 3 databases (PubMed, CINAHL, EMBASE) from January 1975 until April 2010. Prospective, longitudinal studies that assessed the predictive value of individual physical frailty indicators on ADL disability in community-dwelling elderly people aged 65 years and older were eligible for inclusion. Articles were reviewed by two independent reviewers who also assessed the quality of the included studies.
After initial screening of 3081 titles, 360 abstracts were scrutinized, leaving 64 full text articles for final review. Eventually, 28 studies were included in the review. The methodological quality of these studies was rated by both reviewers on a scale from 0 to 27. All included studies were of high quality with a mean quality score of 22.5 (SD 1.6). Findings indicated that individual physical frailty indicators, such as weight loss, gait speed, grip strength, physical activity, balance, and lower extremity function are predictors of future ADL disability in community-dwelling elderly people.
This review shows that physical frailty indicators can predict ADL disability in community-dwelling elderly people. Slow gait speed and low physical activity/exercise seem to be the most powerful predictors followed by weight loss, lower extremity function, balance, muscle strength, and other indicators. These findings should be interpreted with caution because the data of the different studies could not be pooled due to large variations in operationalization of the indicators and ADL disability across the included studies. Nevertheless, our study suggests that monitoring physical frailty indicators in community-dwelling elderly people might be useful to identify elderly people who could benefit from disability prevention programs.
PMCID: PMC3142492  PMID: 21722355
17.  Psychosocial factors modify the association of frailty with adverse outcomes: a prospective study of hospitalised older people 
BMC Geriatrics  2014;14(1):108.
Frailty increases the risk of adverse outcomes in older people. The impact of psychosocial factors on frailty and adverse clinical outcomes associated with frailty has not yet been examined in the hospital setting. The aims of this study were to: i) investigate the association between psychosocial factors and frailty, and ii) to establish whether psychosocial factors impact on the association between frailty and adverse outcomes.
Data was collected from a Geriatric Evaluation and Management Unit (GEMU) in Australia. Frailty was identified using Fried’s frailty criteria. Psychosocial factors included wellbeing, sense of control (mastery), social activities, home/neighbourhood satisfaction, social relationships, anxiety and depression. Outcome measures were: mortality at 12 months, long length of GEMU stay (LOS), 1-month emergency rehospitalisation, and a higher level of care needed on discharge. Covariates adjusted for were age, gender and comorbidity.
The mean (SD) age of participants (n = 172) at admission was 85.2 (6.4) years, with 129 (75%) female patients. 96 (56%) patients were classified as frail, with 64 (37%) pre-frail and 12 (7%) robust. Frail patients had an increased likelihood of 12-month mortality (HR, 95% CI = 3.16, 1.36–7.33), discharge to a higher level of care (OR, 95% CI = 2.40, 1.21–4.78), long LOS (OR, 95% CI = 2.04, 1.07–3.88) and 1-month emergency rehospitalisation (OR, 95% CI = 2.53, 1.10–5.82). Psychosocial factors associated with frailty included poor wellbeing, anxiety, depression, and a low sense of control. Several psychosocial factors increased the likelihood of adverse outcomes associated with frailty, including anxiety and low ratings for: wellbeing, sense of control, social activities and home/neighbourhood satisfaction.
Our results indicate that frail older adults with low psychosocial resources had an elevated risk of mortality, discharge to higher level care, long LOS and rehospitalisation. Consideration of psychosocial factors in comprehensive geriatric assessments will assist in patient care planning.
Electronic supplementary material
The online version of this article (doi:10.1186/1471-2318-14-108) contains supplementary material, which is available to authorized users.
PMCID: PMC4190287  PMID: 25262425
Frail elderly; Psychosocial factors; Geriatric assessment/methods; Hospitalisation
18.  A Frailty Instrument for primary care for those aged 75 years or more: findings from the Survey of Health, Ageing and Retirement in Europe, a longitudinal population-based cohort study (SHARE-FI75+) 
BMJ Open  2014;4(12):e006645.
To create and validate a frailty assessment tool for community-dwelling adults aged ≥75 years.
Longitudinal, population-based study.
The Survey of Health, Ageing and Retirement in Europe (SHARE).
4001 women and 3057 men aged ≥75 years from the second wave of SHARE. 3325 women and 2587 men had complete information for the frailty indicators: fatigue, low appetite, weakness, observed gait (walking without help, walking with help, chairbound/bedbound, unobserved) and low physical activity.
Main outcome measures
The internal validity of the frailty indicators was tested with latent class analysis, by modelling an underlying variable with three ordered categories. The predictive validity of the frailty classification was tested against 2-year mortality and 4-year disability. The mortality prediction of SHARE-FI75+ was compared with that of previously operationalised frailty scales in SHARE (SHARE-FI, 70-item index, phenotype, FRAIL).
In both genders, all frailty indicators significantly aggregated into a three-category ordinal latent variable. After adjusting for baseline age, comorbidity and basic activities of daily living (BADL) disability, the frail had an OR for 2-year mortality of 2.2 (95% CI 1.2 to 3.8) in women and 4.2 (2.6 to 6.8) in men. The mortality prediction of SHARE-FI75+ was similar to that of the other SHARE frailty scales. By wave 4, 49% of frail women (78 of 159) had at least one more limitation with BADL (compared with 18% of non-frail, 125 of 684; p<0.001); in men, these proportions were 39% (26 of 66) and 18% (110 of 621), respectively (p<0.001). A calculator is supplied for point-of-care use, which automatically replicates the frailty classification for any given measurements.
SHARE-FI75+ could help frailty case finding in primary care and provide a focus for personalised community interventions. Further validation in trials and clinical programmes is needed.
PMCID: PMC4275665  PMID: 25537787
Frail Elderly; Screening; Geriatric Assessment; Primary Health Care; Validation Studies; Longitudinal Survey
19.  Frailty and cardiovascular risk in community-dwelling elderly: a population-based study 
Evidence suggests a possible bidirectional connection between cardiovascular disease (CVD) and the frailty syndrome in older people.
To verify the relationship between CVD risk factors and the frailty syndrome in community-dwelling elderly.
This population-based study used data from the Fragilidade em Idosos Brasileiros (FIBRA) Network Study, a cross-sectional study designed to investigate frailty profiles among Brazilian older adults. Frailty status was defined as the presence of three or more out of five of the following criteria: unintentional weight loss, weakness, self-reported fatigue, slow walking speed, and low physical activity level. The ascertained CVD risk factors were self-reported and/or directly measured hypertension, diabetes mellitus, obesity, waist circumference measurement, and smoking.
Of the 761 participants, 9.7% were characterized as frail, 48.0% as pre-frail, and 42.3% as non-frail. The most prevalent CVD risk factor was hypertension (84.4%) and the lowest one was smoking (10.4%). It was observed that among those participants with four or five risk factors there was a higher proportion of frail and pre-frail compared with non-frail (Fisher’s exact test: P=0.005; P=0.021). Self-reported diabetes mellitus was more prevalent among frail and pre-frail participants when compared with non-frail participants (Fisher’s exact test: P≤0.001; P≤0.001). There was little agreement between self-reported hypertension and hypertension identified by blood pressure measurement.
Hypertension was highly prevalent among the total sample. In addition, frail and pre-frail older people corresponded to a substantial proportion of those with more CVD risk factors, especially diabetes mellitus, highlighting the need for preventive strategies in order to avoid the co-occurrence of CVD and frailty.
PMCID: PMC4199970  PMID: 25336932
frailty syndrome; cardiovascular disease; hypertension; aged
20.  Prospective association of the SHARE-operationalized frailty phenotype with adverse health outcomes: evidence from 60+ community-dwelling Europeans living in 11 countries 
BMC Geriatrics  2013;13:3.
Among the many definitions of frailty, the frailty phenotype defined by Fried et al. is one of few constructs that has been repeatedly validated: first in the Cardiovascular Health Study (CHS) and subsequently in other large cohorts in the North America. In Europe, the Survey of Health, Aging and Retirement in Europe (SHARE) is a gold mine of individual, economic and health information that can provide insight into better understanding of frailty across diverse population settings. A recent adaptation of the original five CHS-frailty criteria was proposed to make use of SHARE data and measure frailty in the European population. To test the validity of the SHARE operationalized frailty phenotype, this study aims to evaluate its prospective association with adverse health outcomes.
Data are from 11,015 community-dwelling men and women aged 60+ participating in wave 1 and 2 of the Survey of Health, Aging and Retirement in Europe, a population-based survey. Multivariate logistic regression analyses were used to assess the 2-year follow up effect of SHARE-operationalized frailty phenotype on the incidence of disability (disability-free at baseline) and on worsening disability and morbidity, adjusting for age, sex, income and baseline morbidity and disability.
At 2-year follow up, frail individuals were at increased risk for: developing mobility (OR 3.07, 95% CI, 1.02-9.36), IADL (OR 5.52, 95% CI, 3.76-8.10) and BADL (OR 5.13, 95% CI, 3.53-7.44) disability; worsening mobility (OR 2.94, 95% CI, 2.19- 3.93) IADL (OR 4.43, 95% CI, 3.19-6.15) and BADL disability (OR 4.53, 95% CI, 3.14-6.54); and worsening morbidity (OR 1.77, 95% CI, 1.35-2.32). These associations were significant even among the prefrail, but with a lower magnitude of effect.
The SHARE-operationalized frailty phenotype is significantly associated with all tested health outcomes independent of baseline morbidity and disability in community-dwelling men and women aged 60 and older living in Europe. The robustness of results validate the use of this phenotype in the SHARE survey for future research on frailty in Europe.
PMCID: PMC3585820  PMID: 23286928
Frailty phenotype; Validation; Adverse outcomes; Population survey; SHARE; BADL disability; IADL disability; Morbidity
21.  Exploring the relationship between national economic indicators and relative fitness and frailty in middle-aged and older Europeans 
Age and Ageing  2013;42(5):614-619.
Background: on an individual level, lower-income has been associated with disability, morbidity and death. On a population level, the relationship of economic indicators with health is unclear.
Objective: the purpose of this study was to evaluate relative fitness and frailty in relation to national income and healthcare spending, and their relationship with mortality.
Design and setting: secondary analysis of data from the Survey of Health, Ageing and Retirement in Europe (SHARE); a longitudinal population-based survey which began in 2004.
Subjects: a total of 36,306 community-dwelling people aged 50 and older (16,467 men; 19,839 women) from the 15 countries which participated in the SHARE comprised the study sample. A frailty index was constructed as the proportion of deficits present in relation to the 70 deficits available in SHARE. The characteristics of the frailty index examined were mean, prevalence of frailty and proportion of the fittest group.
Results: the mean value of the frailty index was lower in higher-income countries (0.16 ± 0.12) than in lower-income countries (0.20 ± 0.14); the overall mean frailty index was negatively correlated with both gross domestic product (r = −0.79; P < 0.01) and health expenditure (r = −0.63; P < 0.05). Survival in non-frail participants at 24 months was not associated with national income (P = 0.19), whereas survival in frail people was greater in higher-income countries (P < 0.05).
Conclusions: a country's level of frailty and fitness in adults aged 50+ years is strongly correlated with national economic indicators. In higher-income countries, not only is the prevalence of frailty lower, but frail people also live longer.
PMCID: PMC3745086  PMID: 23443511
ageing; frailty; Europe; SHARE; older people
22.  Frailty and 10-year mortality in community-living Mexican American older adults 
Gerontology  2009;55(6):644-651.
The older Hispanic population of the United States is growing rapidly. Hispanic older adults have relatively high risk-profiles for increased morbidity and disability, yet little is known about how the construct of frailty is related to health trajectories in this population.
The purpose of this study was to examine the relationship between frailty and 10-year mortality in older community-dwelling Mexican Americans.
Data were from the Hispanic Established Populations for Epidemiologic Studies of the Elderly and included 1,996 Mexican Americans, aged 65 and older, living in the southwestern U.S. Primary measures included mortality and a 5-item frailty index comprised of weight loss, exhaustion, walking speed, grip strength, and physical activity.
Mean baseline age was 74.5 yrs (sd 6.1) and 58.5% were women. Baseline frailty assessments yielded the following distribution: 44.9% non-frail, 47.3% pre-frail, and 7.8% frail. Overall, 892 (44.7%) participants died during the 10 year study period. Hazard ratios (HR), adjusted for sociodemographic, health, and medical factors, demonstrated increased odds for mortality in the pre-frail (HR = 1.25: CI95% 1.07, 1.46) and frail (HR = 1.81: CI95% 1.41, 2.31) groups compared to the non-frail cohort.
The 5-item frailty index differentiated odds of 10 year mortality in older community-dwelling Mexican Americans. This clinical index has the potential to identify older minorities at risk for poor health outcomes and mortality.
PMCID: PMC2783319  PMID: 19690395
aging; frail elderly; Hispanic Americans; minorities; survival
23.  Frailty and 10-Year Mortality in Community-Living Mexican American Older Adults 
Gerontology  2009;55(6):644-651.
The older Hispanic population of the United States is growing rapidly. Hispanic older adults have relatively high-risk profiles for increased morbidity and disability, yet little is known about how the construct of frailty is related to health trajectories in this population. Objective: The purpose of this study was to examine the relationship between frailty and 10-year mortality in older community-dwelling Mexican Americans.
Data were from the Hispanic Established Populations for Epidemiologic Studies of the Elderly and included 1,996 Mexican Americans, aged 65 and older, living in the southwestern US. Primary measures included mortality and a 5-item frailty index comprised of weight loss, exhaustion, walking speed, grip strength, and physical activity.
Mean baseline age was 74.5 years (SD 6.1) and 58.5% were women. Baseline frailty assessments yielded the following distribution: 44.9% non-frail, 47.3% pre-frail, and 7.8% frail. Overall, 892 (44.7%) participants died during the 10-year study period. Hazard ratios (HR), adjusted for sociodemographic, health, and medical factors, demonstrated increased odds for mortality in the pre-frail (HR = 1.25, 95% confidence interval, CI95%, 1.07–1.46) and frail (HR = 1.81, CI95% 1.41–2.31) groups compared to the non-frail cohort.
The 5-item frailty index differentiated odds of 10-year mortality in older community-dwelling Mexican Americans. This clinical index has the potential to identify older minorities at risk for poor health outcomes and mortality.
PMCID: PMC2783319  PMID: 19690395
Aging; Frail elderly; Hispanic Americans; Minorities; Survival
24.  Changes in relative fitness and frailty across the adult lifespan: evidence from the Canadian National Population Health Survey 
The prevalence of frailty increases with age in older adults, but frailty is largely unreported for younger adults, where its associated risk is less clear. Furthermore, less is known about how frailty changes over time among younger adults. We estimated the prevalence and outcomes of frailty, in relation to accumulation of deficits, across the adult lifespan.
We analyzed data for community-dwelling respondents (age 15–102 years at baseline) to the longitudinal component of the National Population Health Survey, with seven two-year cycles, beginning 1994–1995. The outcomes were death, use of health services and change in health status, measured in terms of a Frailty Index constructed from 42 self-reported health variables.
The sample consisted of 14 713 respondents (54.2% women). Vital status was known for more than 99% of the respondents. The prevalence of frailty increased with age, from 2.0% (95% confidence interval [CI] 1.7%–2.4%) among those younger than 30 years to 22.4% (95% CI 19.0%–25.8%) for those older than age 65, including 43.7% (95% CI 37.1%–50.8%) for those 85 and older. At all ages, the 160-month mortality rate was lower among relatively fit people than among those who were frail (e.g., 2% v. 16% at age 40; 42% v. 83% at age 75 or older). These relatively fit people tended to remain relatively fit over time. Relative to all other groups, a greater proportion of the most frail people used health services at baseline (28.3%, 95% CI 21.5%–35.5%) and at each follow-up cycle (26.7%, 95% CI 15.4%–28.0%).
Deficits accumulated with age across the adult spectrum. At all ages, a higher Frailty Index was associated with higher mortality and greater use of health care services. At younger ages, recovery to the relatively fittest state was common, but the chance of complete recovery declined with age.
PMCID: PMC3091935  PMID: 21540166
25.  Measures of frailty in population-based studies: an overview 
BMC Geriatrics  2013;13:64.
Although research productivity in the field of frailty has risen exponentially in recent years, there remains a lack of consensus regarding the measurement of this syndrome. This overview offers three services: first, we provide a comprehensive catalogue of current frailty measures; second, we evaluate their reliability and validity; third, we report on their popularity of use.
In order to identify relevant publications, we searched MEDLINE (from its inception in 1948 to May 2011); scrutinized the reference sections of the retrieved articles; and consulted our own files. An indicator of the frequency of use of each frailty instrument was based on the number of times it had been utilized by investigators other than the originators.
Of the initially retrieved 2,166 papers, 27 original articles described separate frailty scales. The number (range: 1 to 38) and type of items (range of domains: physical functioning, disability, disease, sensory impairment, cognition, nutrition, mood, and social support) included in the frailty instruments varied widely. Reliability and validity had been examined in only 26% (7/27) of the instruments. The predictive validity of these scales for mortality varied: for instance, hazard ratios/odds ratios (95% confidence interval) for mortality risk for frail relative to non-frail people ranged from 1.21 (0.78; 1.87) to 6.03 (3.00; 12.08) for the Phenotype of Frailty and 1.57 (1.41; 1.74) to 10.53 (7.06; 15.70) for the Frailty Index. Among the 150 papers which we found to have used at least one of the 27 frailty instruments, 69% (n = 104) reported on the Phenotype of Frailty, 12% (n = 18) on the Frailty Index, and 19% (n = 28) on one of the remaining 25 instruments.
Although there are numerous frailty scales currently in use, reliability and validity have rarely been examined. The most evaluated and frequently used measure is the Phenotype of Frailty.
PMCID: PMC3710231  PMID: 23786540
Frailty; Frail elderly; Measure; Overview; Reliability; Validity

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