grip strength test

Grip strength is a common component in testing for physical frailty.

There are dozens of instruments that have the term ‘frailty’ in the title.  When selecting a frailty assessment instrument for research or to inform clinical care, it is important to identify an instrument that best fits the purpose of the study or clinical need.  Indeed, it is increasingly recognized that a frailty measure should be chosen with care to address the research question most directly (Buta et al., 2016Martin & Brighton, 2008).  The choice is made easier by understanding the differences between the major approaches to frailty measurement, and the conceptual differences between these schools of thought around frailty definitions (see Definitions of Frailty).

It is important to note that the sub-groups deemed frail by different methods often have minimal overlap (Cigolle et al., 2009; Xue et al., 2019).  Therefore, frailty instruments, especially those in differing categories, should not be considered to be interchangeable.  They may include different measures from different domains (e.g., physical function, cognition nutrition).

Frailty instruments have been used for a number of different purposes in research studies; please see Matching the Assessment Method to the Goal for further detail.  We suggest that certain measures may be better suited for different purposes: for example, as a quick screening instrument (e.g., the FRAIL Scale), as a method to measure frailty in an electronic medical records system (e.g., the Deficit Accumulation Index), or as an instrument to study physical frailty as distinct from multimorbidity or disability (e.g., the Physical Frailty Phenotype).  Each of these instruments, and more, are detailed in the following sections.

Here we present a summary of selected frailty assessment instruments, organized by three major schools of thought that support different approaches to the measurement of frailty.  Though frailty research at Johns Hopkins has pioneered and primarily focused on physical frailty, we recognize and highlight the importance and utility of a broad range of frailty concepts and assessments, and work here to clarify important differences.

Please note: The following list of frailty instruments within each category is not meant to be exclusive or exhaustive; rather it is intended to provide an overview of commonly-used instruments, their potential utility, as well as access to specific assessments.

Category I. Physical Frailty Assessment: The assessment of physical frailty is most commonly performed using the physical frailty phenotype. Scores from this assessment predict adverse outcomes in many different patient populations —that is, worsening chronic disease, loss of ability to bounce back from physical stressors such as injuries or surgeries, new or worsening disability, health crises such as falls or hospitalizations, entering a nursing home, and early mortality.

Assessment Name Reference(s) Items Measured Scoring Assessment Resources Considerations for Use
Physical Frailty Phenotype (PFP; commonly called the frailty phenotype, Fried phenotype, or CHS frailty phenotype) Fried et al., 2001;
Bandeen-Roche et al., 2006		 Slowness (measured walking tests)
Low Activity (physical activity questionnaire) Weight Loss (unintentional weight loss)
Exhaustion (questions on energy expenditure) Weakness (measured grip strengths tests)		 Score range: 0 to 5.
Frail = ≥3 criteria present. Intermediate / prefrail = 1-2 criteria present. Robust / non-frail= 0 criteria present.		 PFP Definition sheet.

Hopkins Frailty Assessment Calculator.
  • Time to complete: 5-10 minutes.
  • Requires space for a walking course.
  • Requires a handgrip dynamometer, a stopwatch, scale & stadiometer.
  • There have been many modifications made in research studies (Theou  et al. 2015), including versions that replace objective measures with self-report.
  • For a modified PFP used in the NHANES study, please see Crow et al, 2018.

Additional assessments of physical frailty include the Study of Osteoporotic Fractures Frailty Measure and the Women’s Health Initiative Observational Study (WHI-OS) frailty measure:

Assessment Name Reference(s) Items Measured Scoring Assessment Resources Considerations for Use
Study of Osteoporotic Fracture (SOF) frailty measure Ensrud et al, 2008
Ensrud et al, 2009		 Weight loss (5% or more)
Self-report energy (not feeling full of energy)
Chair rise (unable to rise from five consecutive times)		 Score range: 0 to 3.
Frail = ≥2 criteria present. Pre-frail = 1 criteria present.
Robust = 0 criteria present.		 SOF Index Definition sheet.
  • Time to complete: 5-10 min.
  • Requires space for chair stands.
  • Validated in women (SOF) and men (MrOS)
  • Validated with the PFP.
Women’s Health Initiative Observational Study (WHI-OS) frailty measure Woods et al., 2005 Slowness / Weakness (Rand-36 Physical Function Scale)
Poor Endurance/exhaustion (Rand-36 Vitality Score)
Physical Activity (Detailed physical activity questionnaire)
Unintentional weight loss (5% or more)		 Score range: 0 to 5.
Frail = ≥3 criteria present. Intermediate / prefrail = 1-2 criteria present. Robust / non-frail= 0 criteria present.Note: Slowness / Weakness criterion is assigned 2 points.		 WHI-OS Frailty Measure Definition Sheet.
  • Time to complete: 5-10 minutes.
  • Similar to PFP, but uses Rand-36 questionnaire in place of objective walking speed and grip strength measures.

Category II. Deficit Accumulation Assessment:  This assessment characterizes frailty through the lens of many illnesses and health problems–“deficits.” A frailty index score is calculated as the proportion of potential deficits an individual has. The more problems accumulated, the more frail an individual is considered to be. Like physical frailty, deficit accumulation frailty predicts adverse outcomes.

Assessment Name Reference(s) Items Measured Scoring Assessment Resources Considerations for Use
Deficit Accumulation Index (DAI; commonly called the Frailty index) Mitnitski et al., 2001;  Rockwood et al., 2007 Scales vary in content and number of items but generally include 30-70 items from multiple domains (laboratory findings, physical function problems or disabilities, diseases, symptoms, sensory or cognition difficulties, and other health problems) Number of deficits present and divided by the number of deficits taken into consideration. Higher proportion equates to a higher level of frailty. DAI Definition sheet.

The Frailty Index, Dalhousie University.

“A standard procedure for creating a frailty index”.
  • Time to complete: varies depending on number and type of measures included.
  • Numerous variations exist, including FI-CGA, FI-NH, FI-LAB.
  • Also, FI scales designed for ease of use or screening with more limited items (Subramaniam et al., 2018).
  • Could be useful when only EMR data is available.

Another assessment of deficit accumulation-type frailty is the Edmonton Frail Scale:

Assessment Name Reference(s) Items Measured Scoring Assessment Resources Considerations for Use
Edmonton Frail Scale (EFS) Rolfson et al., 2006 10 items: Cognition (Clock drawing test), Functional Performance (Balance and Mobility using Timed-up-and-go), and self-reported items: General Health, Functional Independence, Social Support, Medication Use, Nutrition, Mood, Continence. Each item is scored, and then all scores are summed out of 17 points possible. EFS Definition sheet.

EFS Calculator.
  • Time to complete: 5 minutes or less.
  • Requires space for timed-up-and-go test.
  • Requires stopwatch.
  • Requires paper, pen, writing surface for the clock drawing test.

Category III. Pre-Disability Assessment: This assessment model has emerged as a definition of frailty that posits frailty as a precursor to overt disability in older persons. This definition has been operationalized using the Short Physical Performance Battery (SPPB) as a SPPB score of 3-9 among persons with no mobility disability (Cesari et al., 2017).

Assessment Name Reference(s) Items Measured Scoring Assessment Resources Considerations for Use
SPPB as a frailty measure Cesari et al., 2017.

See also: Bandinelli et al., 2006.

 Walking speed
Chair Test
Balance Tests		 SPPB score of 3-9 among persons with no mobility disability (defined as not able  to complete a 400 meter walk test in 15 minutes) SPPB Frailty Measure Definition sheet.

SPPB – NIA Toolbox.
  • Time to complete: 5-10 minutes.
  • Requires space for chair stands, walking speed, and balance tests.
  • Requires stopwatch.

Other assessments with a similar pre-disability focus include the Gill Frailty Measure (Gill et al., 2002); gait speed as a single measure (Abellan van Kan et al., 2009); and the Vulnerable Elders Survey (VES-13; Saliba et al., 2001).

Additional Frailty Assessments: The following assessments may not fit cleanly into the categories above. They often include a mix of, or notable variation on, these approaches.

Assessment Name Reference(s) Items Measured Scoring Assessment Resources Considerations for Use
FRAIL Scale Abellan van Kan et al., 2008.

Morley et al., 2012

 Fatigue
Resistance (ability to climb 1 flight of stairs)
Ambulation (ability to walk 1 block)
Illnesses (greater than 5)
Loss of Weight (>5%)
All items are self-reported.		 Score range 0 to 5. No frailty = 0 deficits. Intermediate frailty = 1 or 2 deficits. Frailty = 3 or more deficits. FRAIL Scale Definition sheet.

See also: Appendix in Morley et al., 2012
  • Time to complete: Less than 5 minutes.
  • Similar to the PFP but includes a question about diseases instead of low activity.
Clinical Frailty Scale Rockwood et al., 2005. Nine categories:
1) Very fit (robust, active)
2) Well (no active disease but less fit than ‘very fit’)
3) Well, with treated comorbid disease (well-controlled disease symptoms)
4) Apparently vulnerable (not dependent but ‘slowed up’ or with disease symptoms)
5) Mildly frail (limited dependence)
6 )Moderately frail (help needed)
7) Severely frail (completely dependent, but stable)
8) Very severely frail (completely dependent,  approaching end of life)
9) Terminally ill (approaching end of life, with limited life expectancy)		 A clinician assigns one of the seven categories based on observation of the patient and review of medical records. CFS Definition sheet.

See also: Appendix in Chong et al., 2019.
  • Time to complete: varies.
  • Those making the assessment require access to diagnoses and assessments related to  comorbidity, function, falls, delirium, cognitive impairment, and associated features that inform clinical judgments about the severity of frailty.
  • In the 2005 publication, there were 7 categories. The original 7th category, ‘Severely frail,’ has since been split into categories 7-9.
 Gérontopôle Frailty Screening Tool Vellas et al., 2013;

See also: Subra et al., 2012

Tavassoli et al., 2015.

 Part 1: Living alone; weight loss; increased fatigue; increased mobility difficulties; memory problems; slow gait speed.

Part 2: does practitioner think the patient is frail; and if yes, is the patient willing to be assessed for frailty.

 If the patient meets any criteria in the first set of questions, the practitioner then marks whether they think the patient is frail and willing to be assessed. Gérontopôle Frailty Screening Tool Definition sheet.
  • Time to complete: Less than 5 minutes.
  • Intended for use among patients aged 65 years and older without both functional disability (activities of daily living score ≥5/6) and current acute disease.

For additional information on frailty assessment instruments, please see: