Overcoming the stress of selecting a frailty assessment instrument: guidance and considerations.

Research on frailty has exploded over the past two decades. A quick PubMed search of the term shows an exponential increase in the number of frailty-related publications since the early 2000s. 

But the concept of frailty can be diverse in its underlying theory and measurement.

Different frailty measures can identify different groups of people as frail (Cigolle et al., 2009 ; Xue et al., 2019). And different user scenarios may require different types of measures (Buta et al., 2016; Martin & Brighton, 2008). So how do we move past these challenges?

• One option: focus on screening for frailty in order to capture vulnerability early, regardless of the measure.
• Another option: focus on comparing measures to illuminate discrepancies in measurement, and to better inform similarities and differences between measures.
• Or: prioritize the instrument’s ability to predict poor outcomes… or its construct validity relative to geriatric experience and theory… or its strength as a lever to elucidate and address underlying etiology….

Indeed, these approaches are all important. We need to be able to screen for frailty using existing instruments.  We also need to hone in on what information these different measures – which all fall under a blanket term of “frailty” – are actually telling us about the health of older and vulnerable persons. And for certain studies, we need to know how well frailty will predict adverse health events, while also recognizing the importance of other types of validity (Bandeen-Roche et al., 2020).

In an effort to guide researchers and clinicians who plan to assess frailty, we have posted a new section to FrailtyScience.org: “Frailty Assessment Instruments: Guidance on Selecting a Frailty Instrument.”  We aim to stress the importance of selecting an instrument that best fits the purpose of the research or clinical need.  As noted in this section, “certain measures may be better suited for different purposes.”  For example, a frailty assessment may be utilized as a quick screening instrument (e.g., the FRAIL Scale), or 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 multi-morbidity or disability (e.g., the Physical Frailty Phenotype).

The field continues to lack a consensus operational definition of frailty. But if we can account for the distinct features and uses of different instruments, and if we can use language that better clarifies how frailty is assessed (e.g., physical frailty, deficit accumulation frailty, etc.; Walston et al., 2019), we may be able to improve our ability to prevent and manage health risks for vulnerable older adults across a variety of settings.

Please know that we welcome your thoughts and feedback. You can reach me with comments at bbuta@jhu.edu.

Brian Buta is a project administrator and researcher in the Division of Geriatric Medicine and Gerontology at Johns Hopkins University.  He offers his great thanks to Drs. Karen Bandeen-Roche and Qian-Li Xue for their review and feedback during the writing of this post.