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Feeling Healthy? It Might Matter More Than You Think

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By Qian-Li Xue, PhD, Vishaldeep Sekhon, MS 

A simple question – “How would you rate your health?” – might seem too subjective to matter in modern medicine. But evidence is increasingly telling us otherwise.  

In a recent study of more than 7,000 older adults in the United States, we found that this one question can reveal something profound about a person’s future. When compared with a traditional measure of functional decline – physical frailty – it turns out that both more complex calculated metrics and summary statements on how people feel about their health play important, and distinct, roles in predicting survival. 

Physical frailty refers to a state where the body becomes less able to handle everyday challenges, such as illness or injury. It’s typically measured through a combination of measures including weakness, slow walking, low activity, fatigue, and unintended weight loss (The Fried Frailty Phenotype). Unsurprisingly, we found that frailty matters for survival: people who were classified as frail had about twice the risk of death compared with those who were not, even after accounting for age and other health conditions. 

Unexpectedly, self-rated health remained a powerful predictor of mortality even after adjusting for frailty. Participants who described their health as “fair” or “poor” had about a 60% higher risk of death compared to those reporting “excellent” or “very good” health, regardless of their frailty status.  Importantly, frailty and self-rated health did not always align. While many frail individuals said their health was poor, some still described it as excellent or very good. On the flip side, some people who were not frail felt that their health was poor.  

These mismatches are not just quirks, they are clues and account for the independent prediction of the two variables. They suggest that clinical assessments and personal perceptions each reveal different sides of the same reality. How people feel about their health is not just a reflection of medical diagnoses. It appears to capture something broader – mental well-being, social connections, expectations, all of which impact on the ability to cope with aging beyond the physical limitations imposed by disease and frailty status. 

One interpretation is that self-rated health may serve as a marker of resilience – the capacity to adapt to and cope with physical decline. Individuals who maintain a positive outlook despite frailty may possess important psychological or social resources that support longevity. However, the study also revealed a nuanced picture. Frail individuals with highly favorable self-rated health did not necessarily have better survival than non-frail individuals who rated their health poorly. Optimism, it seems, is not always or limitlessly protective. We speculate that in some cases, it could even lead to missed warning signs or delayed care. 

These findings show why it’s important to look at both medical measures and personal perceptions when assessing health. Clinical indicators like frailty tell us about the body’s physical condition, while self-rated health reflects how people experience and cope with their health in daily life. Neither one alone gives the full picture – both are needed to better understand health risks in older adults. 

For clinicians, this means that asking patients how they perceive their health is not a trivial exercise. It is a meaningful part of assessment. For individuals, it’s a reminder that paying attention to both our bodies and our lived experience matters. And for researchers, it means recognizing that complex outcomes like longevity are unlikely to be fully understood through either objective clinical measures or subjective health assessments alone. Future research should consider how these different dimensions of health interact in shaping outcomes in later life. 

Medicine often strives for precision through numbers and measurements. But sometimes, one of the most powerful insights begins with a question and the willingness to take the answer seriously. 

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.