Simplifying Frailty Assessment in Kidney Transplant Patients: Introducing the Abridged Frailty Phenotype

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Evelien Quint, MD

Evelien Quint, MD

PhD Candidate, Division of Transplant Surgery, Department of Surgery, University Medical Center Groningen

Image of Human Kidneys by Unknown Author is licensed under Creative Commons BY
Image of Human Kidneys by Unknown Author is licensed under Creative Commons BY

It’s widely known that frailty is associated with poor outcomes in surgical patients including kidney transplant patients. National projections estimate that 16.4% of transplant candidates and 14.3% of recipients are frail (Haugen et al, 2020). Remarkably, transplant centers that measure frailty achieve better pre- and post-operative outcomes (Chen et al, 2022). However, frailty assessments aren’t consistently used at transplant centers for many reasons, with time constraints being a significant barrier (McAdams-DeMarco et al, 2020). Therefore, we sought to create a more condensed frailty assessment that does not compromise on discrimination of clinical outcomes.

In our recent study published in The Journals of Gerontology, we propose a new frailty assessment, the abridged frailty phenotype (Chen et al, 2023). The abridged physical frailty phenotype was developed by simplifying the five physical frailty phenotype components (Fried et al, 2001) in a two-center prospective cohort of 3,220 kidney transplant candidates (Table 1). We found that the physical frailty phenotype and abridged assessment identified 23.8% and 27.4% candidates as frail, respectively. The abridged frailty physical phenotype had substantial agreement (kappa = 0.69, 95% CI: 0.66–0.71) with the physical frailty phenotype and excellent discrimination of it (AUC = 0.861). Among a subset of 20 patients at evaluation, the abridged assessment took 5–7 minutes to complete. The physical frailty phenotype and abridged assessment had similar associations with waitlist mortality (subdistribution hazard ratio [SHR] = 1.62, 95% CI: 1.26–2.08 vs SHR = 1.70, 95% CI: 1.33–2.16) and comparable mortality discrimination, using Harrell’s C-statistic (p = .51).

The results of this study support the use of this novel, validated light-touch frailty phenotype in clinical settings. It offers a cost-effective, objective measure of frailty that is both easier and more efficient to use when compared to the original physical frailty phenotype. Importantly, it maintains high accuracy in identifying frail and non-frail patients. Therefore, transplant departments should consider utilizing the abridged assessment to evaluate frailty in patients when time is limited.

It’s important to note that our aim is not to add yet another frailty assessment to the existing arsenal (Buta et al, 2016). In 2018, the American Society of Transplantation concluded that “a standard, validated measure of frailty is yet to be established” for the field (Kobashigawa et al, 2019). We hope that the abridged physical frailty phenotype can fill this gap and become universally accepted across disciplines. Standardization is essential when we discuss frailty; we must ensure that we are all speaking the same language by using consistent tools for measurement.

In conclusion, the development of the abridged physical frailty phenotype represents a step forward in improving the care and outcomes of our patients. Its simplicity, efficiency and effectiveness make it a valuable addition to the toolkit of providers and researchers alike, paving the way for standardized frailty assessment in the future.

Table 1. Components of the original physical frailty phenotype (PFP) and the abridged physical frailty phenotype.

This work was supported by NIH grant R01AG055781 (PI: McAdams-DeMarco).  Dr. Quint was a visiting scholar at NYU Grossman School of Medicine while working on the publication.

Towards a self-reported assessment of physical frailty: updates and challenges

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Brian Buta, MHS

Brian Buta, MHS

Project Administrator, Geriatric Medicine
Johns Hopkins University School of Medicine

Physical frailty is commonly defined by the Physical Frailty Phenotype (Fried et al, 2001), which uses a combination of self-report and objective measures. Physical frailty is a powerful predictor of health outcomes, but it is rarely used outside of research settings because of challenges with implementation. In a busy clinical setting, performing repeated grip strength and timed walking tests is rarely feasible. Self-report questionnaires, in contrast, are easily administered both in the office and even at home for telemedicine visits. Currently, fully self-reported assessments, such as the FRAIL Scale, are not strongly correlated with the PFP (Aguayo et al, 2017).  We therefore set out to develop a self-reported tool that would correlate well with physical frailty, and thus be useful in settings with time and resource constraints.

In our recent study published in the BMC Geriatrics, we tested several possible self-reported frailty phenotypes which included different combinations of questions focused on slowness and weakness (Buta et al, 2022). When we substitute sets of 3 questions for each of the objective measures in the PFP there was substantial agreement between standard and self-reported measures of physical frailty for a 2-level model of frail/non-frail (Kappa=0.76– 0.78). We also found the highest sensitivity (86.4%) and negative predictive value (98.7%) for identifying frail older adults when comparing the standard PFP to a self-reported version that included these 3 slowness- and 3 weakness-related questions. The self-report tool took participants less than 5 minutes to complete.

Table of Physical Frailty Measures/ Criteria Assessed in this Study

We found only fair-to-moderate levels of agreement in a 3-level model that categorized participants as either frail, pre-frail or non-frail. Also, the generalizability of our findings may be limited by the study population of aging registry participants from the Baltimore area. Compared to US national demographics (US Census Bureau), our study population had a higher prevalence of participants who were female; African American; and had completed a bachelor’s degree or higher.

Clinician with hispanic female older adultOur results show the utility as well as the challenges of using self-reported questions to identify a frailty phenotype in clinic. Additional testing in general clinic populations should be done, with refinement of the questionnaire as needed, since a self-reported physical frailty measure with high agreement to the standard phenotype will be a valuable frailty screening assessment in both clinical and telehealth settings. To this end, we have recently published complementary work in a larger epidemiological study that highlights the importance of selecting viable self-report measures: common self-reported disability questions do not appear to serve as strong proxies for the physical frailty phenotype’s performance-based measures (Bandeen-Roche et al, 2023). Additional efforts to simplify the assessment of physical frailty are ongoing (Chen et al, 2023).

The results of this study suggest that a self-report assessment would be valuable as a screening tool if it has low rate of “false negatives”–that is we are unlikely to miss people who would be categorized as frail by the standard phenotype.  In order to optimize clinical intervention early in the course of physical frailty, a sensitive screening tool that is easy to administer followed by targeted objective tests to confirm frailty is an efficient strategy but depends on the effectiveness of the interventions. In Europe, a population wide, app-based frailty screening effort is underway that includes interventional targets following screening and comprehensive evaluation (Subra, 2012). It will be important in the future to follow up this research with high quality intervention studies.

What Can Digital Health do for Geriatric Oncology? – advancing equity and meaningful use

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Nabiel Mir, MD

Nabiel Mir, MD

Geriatric Oncology Fellow, University of Chicago Medicine

Frailty, Oncology, and the Geriatric Assessment

Frailty in older adults with cancer is associated with poor outcomes such as mortality (Augustin et al., 2016; Soubeyran et al., 2012), functional decline (Hoppe et al., 2013) and toxicity from chemotherapy (Hurria et al., 2011). Major organizations like the American Society of Clinical Oncology recommend using a comprehensive geriatric assessment (CGA) to identify vulnerabilities such as functional impairment, comorbidities, and cognition as well as institute CGA-driven interventions like exercise or nutritional rehabilitation (Mohile et al., 2018) that have been shown to significantly reduce the risk of high-grade toxicity without compromising survival in vulnerable cohorts with geriatric impairments (Mohile et al., 2020).

Importantly, geriatric assessment improves outcomes even when implemented by physicians other than geriatricians (Moreno et al., 2022). However, surveys of oncologists in 2019 (Dale et al., 2021) and again in 2020 (Gajra et al., 2022) show poor uptake of CGA tools by oncologists, with about 50% being aware of national guidelines (Dale et al., 2021) and 40% using a CGA to inform treatment decisions (Gajra et al., 2022). Better solutions are needed now and beyond to ensure the equitable delivery of guideline-based care; Digital Health Technology (DHT) is poised to be that solution in the coming decade.
Digital Health Technologies

According to the FDA, DHTs include computing platforms, connectivity, software, and sensors for health care and related uses. Examples of DHTs range from mobile applications apps for wellness from generally accessible platforms like Headspace – which aims to provide meditation and stress management to users across the globe – to more specialized applications like Cankado, an electronic patient-reported outcome (ePRO) application that facilitates symptom survey collection for both clinicians and researchers in advanced cancer.

Using tablets or computers to facilitate symptom and CGA survey data collection in older adults has proven feasible (McCleary et al., 2013). Thus, DHT provides an opportunity to increase the use of CGA assessments by non-geriatricians and decrease the burden of collecting such data during time-limited clinical visits. DHT-based ePRO collection could even improve longevity in patients with cancer by more rapidly alerting providers to high-risk situations that patients may not recognize as such, as well as improving the response times and rates by clinical staff providing targeted symptom care (Denis et al., 2019). Wireless sensors and wearable devices could provide clinicians and researchers with surrogate markers of frailty (Razjouyan et al., 2018) as well as cognitive impairment (Razjouyan et al., 2020), and other markers of vulnerability such as falls (Warrington et al., 2021). However, much more work needs to be done to realize a comprehensive vision of a usable and feasible “smart medical home” for older adults with cancer and frail older adults generally.

Barriers to Digital Health Adoption

Equally important is the tremendous potential of such tools, in combination with telehealth conferencing applications, to deliver multidisciplinary CGA interventions to underserved and rural populations (DiGiovanni et al., 2020). With Pew Research data showing that in the past decade, the gap in smartphone adoption between adults in their 60s compared to those in their 20s has shrunk, tablet adoption by older adults has grown to 44%, and in 2022 75% of older adults identify themselves as internet users, DHT seems like an obvious choice for many data collection and communication challenges.
However, a “digital divide” by location and aging impedes the adoption and implementation of DHTs in geriatric oncology. Over 30 million Americans do not have broadband infrastructure access, many of whom are located on Tribal lands. Without access to adequate internet, the ability of DHT to facilitate communication between patients and clinicians is vitiated.

 

Age-related changes in visual, motor, and cognitive function also act as barriers to the implementation of technological tools for older adults, in particular the “screen”-based delivery of many DHT applications (Loh et al., 2018). Navigating websites, compactly spaced keyboard buttons, long sets of instructions, and a sense of medical information overload are commonly reported barriers to the adoption of DHTs by this population (Hasnan et al., 2022). When confronted by surveys that are long or include jargon, older patients are therefore at risk of under-reporting due to mental fatigue or cognitive impairment (Kotronoulas et al., 2021).

Most patients and caregivers report low self-perceived electronic health literacy and less confidence in evaluating online health information for cancer decision-making (Verma et al., 2022). There also exists a complex interaction between the older patients’ sense of well-being and their own assessment of their cognitive abilities, which plays a key role in the adoption of wearable use among older adults (Farivar et al., 2020).
Enhancing Digital Health Equity for Older Adults

Interesting design suggestions to optimize uptake and engagement with DHT by older adults include using image or voice prompts, large font sizes, and more pictures/symbols than words for those with literacy issues (Loh et al., 2018). Perceived usefulness could also be improved by providing recommendations of when to visit the ER, medication lists or physical activity reminders, and access to up-to-date, user-friendly cancer disease status and treatment information (Hasnan et al., 2022). Methods incorporating the patient perspective into DHT development through Human-Centered Design is another important concept. By interviewing older users, and examining all aspects of usability, cyclic user testing, and iterative design, developers of DHT can promote applications with better equity and applicability to the diverse components of this heterogeneous population (Harte et al., 2014).

Unobtrusive monitoring is another potential solution, allowing clinicians to obtain patient data without requiring the direct engagement of the participant. This field has been exploring the feasibility of ambient smart sensors that are already integrated with commonly used home items to provide automated measures of health status (Bokharouss et al., 2007; Rashidi et al., 2010). Testing such solutions and designing them with the needs and values of the intended population is critical to bridging this divide and developing truly equitable solutions.

One of the goals of geriatric oncology is to enhance older adult clinical trial participation so that we may expand the evidence base in this rapidly evolving field. DHTs again have the potential to act as monitors of patient-centric outcomes and thereby enhance the interpretability and generalizability of clinical treatment trials. DHTs can provide a longitudinal health status assessment by reliably collecting measures of well-being, function, and nutrition in addition to ePROs.

Digital health

The Geriatric Remote Initiative (GeRI), led by myself and mentors from both Drug Development and Gero-Tech at the University of Chicago and supported by the Conquer Cancer Foundation’s Young Investigator Award in Geriatric Oncology, is co-designing a cloud-enabled connected-systems platform with startup Prosilient Systems, composed of a tablet, a wearable, and a scale. There has been some preliminary work on sensor-based assessments of frailty (Blinka et al., 2021; Bian et al., 2022). A key feature of this initiative is the participation of key stakeholders, including older patients with cancer, cancer survivors, and caregivers of those with cancer. Thus, our platform will be a novel, technology-based data collection platform, iteratively improved with user feedback and vetted by patients from diverse oncology environments as well as human-centered design specialists able to be adapted and integrated into any geriatric oncology research setting.

Examples of wearable tech for digital health

Excitingly, there are over 100 recruiting Digital Health Studies in Oncology currently registered on ClinicalTrials.gov, ranging from Digital Biomarker discovery to health coaching and symptom management. However, few of these cater to frail adults specifically. As we have seen, barriers to adoption and lack of data supporting DHTs predictive or prognostic capacities in a frail population persist. Such issues need to become a focus of DHT research, given the major effect of frailty on outcomes.

Telehealth: remote assessments of physical function and frailty measures

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Brian Buta, MHS

Brian Buta, MHS

Project Administrator, Geriatric Medicine
Johns Hopkins University School of Medicine

Objective measures of function are critical to both the clinical care of older adults and to research on healthy aging and physical frailty.  While telehealth had already been on the rise in recent years, the COVID-19 pandemic skyrocketed the use of remote and virtual assessments, creating an urgent need to adapt methods for patient care and research data collection to the new environments. Clinicians and investigators, struggling with the need to collect functional information remotely over video conferencing or by telephone, need guidance regarding the safety, feasibility and utility of various options and measures.

With support from the Gerontological Society of America (GSA) Innovation Fund: The Generativity Effect and sponsorship from the GSA Technology and Aging Interest Group, we set out to summarize existing evidence-based recommendations for the safe, accurate administration of objective functional measures during a synchronous, remote visit. We also aimed to summarize alternative subjective assessments that are highly correlated to objective measures but more easily obtained during virtual patient interactions. Our ultimate goal was to develop a set of tip sheets for the administration of functional and frailty assessments during a remote clinical or research visit.

We focused on the components of three commonly-administered objective measures of physical functional and frailty in clinical and research settings: the Short Physical Performance Battery (3-meter or 4-meter usual walk, 5-repeated chair stands, 3 static balance poses), the Timed Up and Go, and the Physical Frailty Phenotype (15-foot usual walk, grip strength).  Our approach included crowdsourcing and literature review on 1) the feasibility, safety, and accuracy of virtual assessments using or adapting these objective measures; 2) the correlation of selected subjective and objective measures of function.

With a collaborating team of interdisciplinary investigators from 10 different U.S. institutions, we completed the literature reviews and summarized our findings.  In brief summary, we found the following:

  • Feasibility, safety, accuracy of virtual assessments: Very limited existing guidelines were uncovered for the administration of virtual functional and frailty measures. Therefore, we created a reference list to guide clinicians and researchers to related expert recommendations on the remote, telehealth administration of assessment and care generally. Important considerations include sensory, cognitive, and physical limitations, as well as adequate physical space and available supervision.
  • Correlation of selected subjective and objective measures of function: Moderate correlations were found between objective performance tests and self-reported measures, except for with grip strength, which had only low correlations with self-reported function. No studies reported extremely high correlations which suggests the different modalities reflect related but distinct domains of function. Small sample sizes / clinical settings can affect generalizability.  Self-reported measures can serve as screening tools for persons at potential risk for functional deficits and when safety concerns preclude virtual objective testing.

Based on these findings, we developed a set of tip sheets that recommend a stepwise approach to the remote / virtual assessment of physical function / frailty for care and/or research purposes. Initial safety screening questions can help identify individuals who may be at the highest risk of injury or who are unlikely to be able to successfully complete the testing during a virtual video call. For this group, we provide a list of subjective functional and frailty questions that have reasonable correlation to act as a surrogate assessment until in-person measures can be safely conducted.  For others, we included a list of supplies needed to carry out testing at home and provided simple instructions for objective measures. The presence of a caregiver or helper on the patient’s or study participant’s end is highly advised.

In conclusion, Telehealth is here to stay. A significant advantage is that the ability to conduct remote visits broadens the reach of geriatric assessment to those who do not have access to local specialized geriatric care, but we need to strengthen our clinical and research methods with additional testing of reliability, reproducibility and safety of remote assessment tools.

We hope you will review the full report and tip sheet that resulted from this work. And we hope that clinicians and researchers will consider standard approaches such as those outlined in the tip sheets in order to help standardize administration protocols and allow better comparison of data across clinical and research samples.

Blog post by Brian Buta, with great thanks to project leader, Megan Huisingh-Scheetz, and to our collaborators and co-authors on this project: Abdulaziz Abaoud, Karen Bandeen-Roche, Margaret Danilovich, John Hall, Erin Harrell, Louise Hawkley, Helen Lach, Michelle Martinchek, Aarti Mathur, Nabiel Mir, Carrie Nieman, Pamela Toto, and Walter Boot.

Middle Aged Couple With Computer Tablet

Advancing the visibility of frailty research: Upcoming spotlight on novel and exciting research questions 

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Brian Buta, MHS

Brian Buta, MHS

Project Administrator, Geriatric Medicine
Johns Hopkins University School of Medicine

The term “frail” has evolved from a catch-all phrase to describe older persons with a wide range of health conditions to a more refined set of theories and definitions that aim to characterize systemic vulnerability to poor health outcomes. Research on frailty has flourished in recent years, and this growing energy to study and utilize our understanding to best improve the health of older adults sits at a tipping point that we believe can benefit from a targeted focus on existing gaps in our frailty-related knowledge.
To this end, BMC Geriatrics has announced a call for a collection of papers focused on frailty research: https://bmcgeriatr.biomedcentral.com/frailty. Categories include: Epidemiology and Measurement; Frailty Biology; Frailty and Clinical Care; and Interdisciplinary Topics. As noted in a recent editorial, there are four topics  highlighted in hopes of advancing the field toward tackling novel and exciting research questions:
1)    Causes of frailty, distinguishing by primary, biologically-driven causes or secondary disease-driven processes that lead to frailty.
2)    Innovative interventions, including targeting frailty itself as well as approaches for care delivery for frail persons
3)    Biological studies of novel biological mechanisms responsible for the generalized physiological dysregulation associated with frailty, specifically omics-based studies
4)    Integrated solutions beyond clinical medicine for identifying and managing frailty
The call for papers for the Frailty collection is open now; please consider submitting your research!
The full editorial by the collection’s Guest Editors, Prof. Ivan Aprahamian and Dr. Qian-Li Xue, is available here: “Shaping the next steps of research on frailty: challenges and opportunities.”

Understanding the etiology underlying frailty: Making frail older adults less frail 

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Karen Bandeen Roche, PhD

Karen Bandeen Roche, PhD

Frank Hurley and Catharine Dorrier Chair of Biostatistics
Johns Hopkins Bloomberg School of Public Health
Co-Director, Johns Hopkins Older Americans Independence Center

Why do older adults grow frail? 

Because they grow old–but not only this. We all know, or we recognize as researchers, that some octogenarians thrive, while others ten years younger are highly vulnerable. 

Our field of gerontology often asks a different question: How should an older adult’s frailty influence the care we provide them? That’s important. So also, though, is to treat the frailty itself: truly treat, and not just ameliorate symptoms. This is what any one of us would wish if we were frail—to not be as frail anymore. 

Our group here at Frailty Science has been pursuing the goal of forestalling and turning back frailty for more than two decades. Which brings us back to the question where we began—why do older adults grow frail? If we knew the answer, maybe we could reverse the process: at least, take it a few steps back. The evidence base we have accrued points to a potential answer: People become physically frail because their physiology reaches a pattern and threshold of dysregulation making it impossible to sustain, even qualitatively, its intended functioning. 

You can imagine how thrilled and privileged we felt recently, then, when Nature Aging published a compendium of our work in its inaugural issue. In brief, we hypothesize that frailty results from critical dysregulation in multiple physiological systems—not any systems, but a few specific systems that are central to stress response, musculoskeletal integrity, and energy metabolism. Dynamical systems theory may then provide a useful lens to recognize impending critical transitioning out of qualitatively “normal” physiological functioning, and emergence into a radically different, frail state of functioning. The component systems—stress response and etc.—would be “modules” in the overarching dynamical system, and then their integrity, protocols for interacting with each other, preservation of redundancies against failures, and the like are parameters governing the overarching functioning. Elegant mathematics are available to characterize these parameters: We believe the parameters’ estimation in the context of stressor perturbation hold promise both as biomarkers of frailty and levers to identify intervention points that could indeed turn back frailty—at least, frailty below a severity threshold where intervention remains possible.  

If you’re interested, we hope you’ll check out this work further: 

Nature Aging Article  

Johns Hopkins Press Release

Frailty and Cognitive Impairment: Time to Acknowledge and Embrace Heterogeneity

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Qian-Li Xue, PhD

Qian-Li Xue, PhD

Associate Professor of Geriatric Medicine
Johns Hopkins University School of Medicine

Frailty and cognitive impairment, two common geriatric conditions, are known to be associated with late-life vulnerability in older adults (Todd et al., 2013; Cesari et al., 2016; Fried et al. 2001). An estimated 15% of non-nursing home older adults in the United States aged 65 and over are frail (Bandeen-Roche et al., 2015), and about 22% and 9% have mild cognitive impairment and dementia (Katz et al. 2012; Langa et al., 2017). Physical frailty and cognitive impairment often co-exist in older adults. However, there are sizeable subgroups who have one but not the other. According to a recent US population-based study published in the Journal of the American Geriatrics Society by Ge and colleagues (Ge et al., 2020), 67% of frail older adults had cognitive impairment, and 29% of older adults with cognitive impairment were frail. That physical frailty and cognitive impairment may not manifest together is reinforced by clinical encounters with older adults who are physically robust but cognitively frail and vice versa. 

The study by Ge et al. also found that individuals with frailty only (meaning without cognitive impairment) had the highest prevalence of obesity, current smoking, multimorbidity, lung disease, and history of surgery. The group with both cognitive impairment and frailty were the oldest on average and had the highest prevalence of dementia, depression, cardiovascular diseases, and disability. It is also worth noting that the prevalence of dementia in the group with both frailty and cognitive impairment was more than doubled compared to the group with cognitive impairment alone. This latter finding makes it plausible that the comorbid status could result from frailty being a sequela of cognitive impairment beyond a certain severity. Alternatively, the joint versus separate occurrence of frailty and cognitive impairment may signal different etiologies and pathways. Preliminary support of the latter came from a recent longitudinal study showing that people on a trajectory to develop dementia were three times more likely to experience concurrent onset of frailty and cognitive impairment than to develop cognitive impairment first (Chu et al., 2019). Taken together, these findings suggest that the co-occurrence of cognitive impairment and frailty may be driven primarily by neurologic pathologies rather than “normal” cognitive aging or physical impairments. By contrast, the group with cognitive impairment only may represent mostly normal cognitive aging with less disease burden, as shown in the study by Ge et al.

The findings above support the value of assessing frailty and cognitive impairment in tandem in clinical settings in order to achieve greater measurement specificity as well as inform the selection and prioritization of treatment targets. For example, the group with frailty only may benefit from tailoring interventions based on specific disease profiles. In contrast, the group with cognitive impairment only may largely reflect non-pathological cognitive aging given their lower dementia prevalence and multimorbidity burden (cardiovascular diseases in particular), and therefore may benefit from lifestyle interventions. The group with comorbid frailty and cognitive impairment on the other hand may benefit from interventions that target both dementia-related pathologies and vascular risk factors to slow down the progression of dementia and the accompanying diseases. Now is the time to embrace a paradigm shift from pursuing research on frailty and cognitive impairment in silos to an integrative and holistic approach by which precision medicine can succeed in caring for older adults.

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

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Brian Buta, MHS

Brian Buta, MHS

Project Administrator, Geriatric Medicine
Johns Hopkins University School of Medicine

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. 

NIH Library of Medicine Search on Frailty

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.