The I.A.N.A. task force on frailty assessment of older people in clinical practice
TL;DR: A comprehensive review of the definitions and assessment tools on frailty in clinical practice and research was performed, combining evidence derived from a systematic review of literature along with an expert opinion of a European, Canadian and American Geriatric Advisory Panel (GAP).
Abstract: Frailty is a commonly used term indicating older persons at increased risk for adverse outcomes such as onset of disability, morbidity, institutionalisation or mortality or who experience a failure to integrate adequate responses in the face of stress. Although most physicians caring for older people recognize the importance of frailty, there is still a lack of both consensus definition and consensual clinical assessment tools. The aim of the present manuscript was to perform a comprehensive review of the definitions and assessment tools on frailty in clinical practice and research, combining evidence derived from a systematic review of literature along with an expert opinion of a European, Canadian and American Geriatric Advisory Panel (GAP). There was no consensus on a definition of frailty but there was agreement to consider frailty as a pre-disability stage. Being disability a consequence rather than the cause of frailty, frail older people do not necessary need to be disabled. The GAP considered that disability (as a consequence of frailty) should not be included in frailty definitions and assessment tools. Although no consensual assessment tool could be proposed, gait speed could represent the most suitable instrument to be implemented both in research and clinical evaluation of older people, as assessment of gait speed at usual pace is a quick, inexpensive and highly reliable measure of frailty.
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Saint Louis University1, French Institute of Health and Medical Research2, Charité3, University of Erlangen-Nuremberg4, The Catholic University of America5, Wright State University6, Columbia University7, University of Maryland, Baltimore8, University of Toronto9, Pennsylvania State University10, Dalhousie University11, University of Antwerp12, Johns Hopkins University13
TL;DR: For the purposes of optimally managing individuals with physical frailty, all persons older than 70 years and all individuals with significant weight loss (>5%) due to chronic disease should be screened for frailty.
2,751 citations
TL;DR: Gait speed at usual pace was found to be a consistent risk factor for disability, cognitive impairment, institutionalisation, falls, and/or mortality in older adults as mentioned in this paper, and the use of simple, safe, and easy to perform assessment tool, like gait speed, to evaluate vulnerability to adverse outcomes in community-dwelling older people is appealing.
Abstract: Introduction: The use of a simple, safe, and easy to perform assessment tool, like gait speed, to evaluate vulnerability to adverse outcomes in community-dwelling older people is appealing, but its predictive capacity is still questioned. The present manuscript summarises the conclusions of an expert panel in the domain of physical performance measures and frailty in older people, who reviewed and discussed the existing literature in a 2-day meeting held in Toulouse, France on March 12-13, 2009. The aim of the IANA Task Force was to state if, in the light of actual scientific evidence, gait speed assessed at usual pace had the capacity to identify community-dwelling older people at risk of adverse outcomes, and if gait speed could be used as a single-item tool instead of more comprehensive but more time-consuming assessment instruments. Methods: A systematic review of literature was performed prior to the meeting (Medline search and additional pearling of reference lists and key-articles supplied by Task Force members). Manuscripts were retained for the present revision only when a high level of evidence was present following 4 pre-selected criteria: a) gait speed, at usual pace, had to be specifically assessed as a single-item tool, b) gait speed should be measured over a short distance, c) at baseline, participants had to be autonomous, community-dwelling older people, and d) the evaluation of onset of adverse outcomes (i.e. disability, cognitive impairment, institutionalisation, falls, and/or mortality) had to be assessed longitudinally over time. Based on the prior criteria, a final selection of 27 articles was used for the present manuscript. Results: Gait speed at usual pace was found to be a consistent risk factor for disability, cognitive impairment, institutionalisation, falls, and/or mortality. In predicting these adverse outcomes over time, gait speed was at least as sensible as composite tools. Conclusions: Although more specific surveys needs to be performed, there is sufficient evidence to state that gait speed identifies autonomous community-dwelling older people at risk of adverse outcomes and can be used as a single-item assessment tool. The assessment at usual pace over 4 meters was the most often used method in literature and might represent a quick, safe, inexpensive and highly reliable instrument to be implemented.
1,459 citations
TL;DR: This study has validated the FRAIL scale in a late middle-aged African American population and is an excellent screening test for clinicians to identify frail persons at risk of developing disability as well as decline in health functioning and mortality.
Abstract: To validate the FRAIL scale. Longitudinal study. Community. Representative sample of African Americans age 49 to 65 years at onset of study. The 5-item FRAIL scale (Fatigue, Resistance, Ambulation, Illnesses, & Loss of Weight), at baseline and activities of daily living (ADLs), instrumental activities of daily living (IADLs), mortality, short physical performance battery (SPPB), gait speed, one-leg stand, grip strength and injurious falls at baseline and 9 years. Blood tests for CRP, SIL6R, STNFR1, STNFR2 and 25 (OH) vitamin D at baseline. Cross-sectionally the FRAIL scale correlated significantly with IADL difficulties, SPPB, grip strength and one-leg stand among participants with no baseline ADL difficulties (N=703) and those outcomes plus gait speed in those with no baseline ADL dependencies (N=883). TNFR1 was increased in pre-frail and frail subjects and CRP in some subgroups. Longitudinally (N=423 with no baseline ADL difficulties or N=528 with no baseline ADL dependencies), and adjusted for the baseline value for each outcome, being pre-frail at baseline significantly predicted future ADL difficulties, worse one-leg stand scores, and mortality in both groups, plus IADL difficulties in the dependence-excluded group. Being frail at baseline significantly predicted future ADL difficulties, IADL difficulties, and mortality in both groups, plus worse SPPB in the dependence-excluded group. This study has validated the FRAIL scale in a late middle-aged African American population. This simple 5-question scale is an excellent screening test for clinicians to identify frail persons at risk of developing disability as well as decline in health functioning and mortality.
1,110 citations
Cites background from "The I.A.N.A. task force on frailty ..."
...A useful frailty scale should be able to predict future disability before the person becomes disabled (9)....
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...The International Association of Nutrition and Aging proposed a frailty scale (FRAIL) that only requires answers to 5 simple questions (9, 10)....
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French Institute of Health and Medical Research1, University of Bordeaux2, King's College London3, University of Valencia4, World Health Organization5, University of Illinois at Urbana–Champaign6, McGill University7, University of Bedfordshire8, Erasmus University Rotterdam9, University of Rennes10, National Institutes of Health11, Columbia University12, Dalhousie University13, Autonomous University of Madrid14, University of Foggia15, Pan American Health Organization16
TL;DR: There is agreement on the usefulness of defining frailty in clinical settings as well as on its main dimensions, however, additional research is needed before an operative definition of frailty can be established.
Abstract: BACKGROUND: There is no consensus regarding the definition of frailty for clinical uses. METHODS: A modified Delphi process was used to attempt to achieve consensus definition. Experts were selected from different fields and organized into five Focus Groups. A questionnaire was developed and sent to experts in the area of frailty. Responses and comments were analyzed using a pre-established strategy. Statements with an agreement more than or equal to 80% were accepted. RESULTS: Overall, 44% of the statements regarding the concept of frailty and 18% of the statements regarding diagnostic criteria were accepted. There was consensus on the value of screening for frailty and about the identification of six domains of frailty for inclusion in a clinical definition, but no agreement was reached concerning a specific set of clinical/laboratory biomarkers useful for diagnosis. CONCLUSIONS: There is agreement on the usefulness of defining frailty in clinical settings as well as on its main dimensions. However, additional research is needed before an operative definition of frailty can be established.
929 citations
Cites background from "The I.A.N.A. task force on frailty ..."
...There is to date no clear consensus regarding the definition of frailty (2,3)....
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TL;DR: On-going and future clinical trials on sarcopenia may radically change the authors' preventive and therapeutic approaches of mobility disability in older people.
Abstract: Sarcopenia is a loss of muscle protein mass and loss of muscle function. It occurs with increasing age, being a major component in the development of frailty. Current knowledge on its assessment, etiology, pathogenesis, consequences and future perspectives are reported in the present review. On-going and future clinical trials on sarcopenia may radically change our preventive and therapeutic approaches of mobility disability in older people.
886 citations
Cites background from "The I.A.N.A. task force on frailty ..."
...Sarcopenia is assumed to be a major component in the development of frailty (23, 24), but that assumption depends on the operational definition used....
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References
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TL;DR: This study provides a potential standardized definition for frailty in community-dwelling older adults and offers concurrent and predictive validity for the definition, and finds that there is an intermediate stage identifying those at high risk of frailty.
Abstract: Background: Frailty is considered highly prevalent in old age and to confer high risk for falls, disability, hospitalization, and mortality. Frailty has been considered synonymous with disability, comorbidity, and other characteristics, but it is recognized that it may have a biologic basis and be a distinct clinical syndrome. A standardized definition has not yet been established.
Methods: To develop and operationalize a phenotype of frailty in older adults and assess concurrent and predictive validity, the study used data from the Cardiovascular Health Study. Participants were 5,317 men and women 65 years and older (4,735 from an original cohort recruited in 1989-90 and 582 from an African American cohort recruited in 1992-93). Both cohorts received almost identical baseline evaluations and 7 and 4 years of follow-up, respectively, with annual examinations and surveillance for outcomes including incident disease, hospitalization, falls, disability, and mortality.
Results: Frailty was defined as a clinical syndrome in which three or more of the following criteria were present: unintentional weight loss (10 lbs in past year), self-reported exhaustion, weakness (grip strength), slow walking speed, and low physical activity. The overall prevalence of frailty in this community-dwelling population was 6.9%; it increased with age and was greater in women than men. Four-year incidence was 7.2%. Frailty was associated with being African American, having lower education and income, poorer health, and having higher rates of comorbid chronic diseases and disability. There was overlap, but not concordance, in the cooccurrence of frailty, comorbidity, and disability. This frailty phenotype was independently predictive (over 3 years) of incident falls, worsening mobility or ADL disability, hospitalization, and death, with hazard ratios ranging from 1.82 to 4.46, unadjusted, and 1.29-2.24, adjusted for a number of health, disease, and social characteristics predictive of 5-year mortality. Intermediate frailty status, as indicated by the presence of one or two criteria, showed intermediate risk of these outcomes as well as increased risk of becoming frail over 3-4 years of follow-up (odds ratios for incident frailty = 4.51 unadjusted and 2.63 adjusted for covariates, compared to those with no frailty criteria at baseline).
Conclusions: This study provides a potential standardized definition for frailty in community-dwelling older adults and offers concurrent and predictive validity for the definition. It also finds that there is an intermediate stage identifying those at high risk of frailty. Finally, it provides evidence that frailty is not synonymous with either comorbidity or disability, but comorbidity is an etiologic risk factor for, and disability is an outcome of, frailty. This provides a potential basis for clinical assessment for those who are frail or at risk, and for future research to develop interventions for frailty based on a standardized ascertainment of frailty.
16,255 citations
TL;DR: The ability of the Clinical Frailty Scale to predict death or need for institutional care, and correlated the results with those obtained from other established tools are determined.
Abstract: Background: There is no single generally accepted clinical definition of frailty. Previously developed tools to assess frailty that have been shown to be predictive of death or need for entry into an institutional facility have not gained acceptance among practising clinicians. We aimed to develop a tool that would be both predictive and easy to use. Methods: We developed the 7-point Clinical Frailty Scale and applied it and other established tools that measure frailty to 2305 elderly patients who participated in the second stage of the Canadian Study of Health and Aging (CSHA). We followed this cohort prospectively; after 5 years, we determined the ability of the Clinical Frailty Scale to predict death or need for institutional care, and correlated the results with those obtained from other established tools. Results: The CSHA Clinical Frailty Scale was highly correlated ( r = 0.80) with the Frailty Index. Each 1-category increment of our scale significantly increased the medium-term risks of death (21.2% within about 70 mo, 95% confidence interval [CI] 12.5%–30.6%) and entry into an institution (23.9%, 95% CI 8.8%–41.2%) in multivariable models that adjusted for age, sex and education. Analyses of receiver operating characteristic curves showed that our Clinical Frailty Scale performed better than measures of cognition, function or comorbidity in assessing risk for death (area under the curve 0.77 for 18-month and 0.70 for 70-month mortality). Interpretation: Frailty is a valid and clinically important construct that is recognizable by physicians. Clinical judgments about frailty can yield useful predictive information.
5,189 citations
"The I.A.N.A. task force on frailty ..." refers methods in this paper
...In a second working group, Rockwood measured frailty with the CHSA Clinical Frailty Scale, a seven-point scale based upon a frailty index of 70 items: (24) 1....
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...(24) Frailty was assessed by the CSHA, frailty scale, a 7-point clinical frailty scale based upon a 70-item CHSA frailty index....
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TL;DR: A narrative review of current understanding of the definitions and distinguishing characteristics of each of these conditions, including their clinical relevance and distinct prevention and therapeutic issues, and how they are related is provided.
Abstract: Three terms are commonly used interchangeably to identify vulnerable older adults: comorbidity, or multiple chronicconditions,frailty, anddisability. However, in geriatricmedicine,there isagrowingconsensusthatthese are distinct clinical entities that are causally related. Each, individually, occurs frequently and has high import clinically. This article provides a narrative review of current understanding of the definitions and distinguishing characteristics of each of these conditions,including theirclinical relevance and distinct prevention and therapeutic issues, and how they are related. Review of the current state of published knowledge is supplemented by targeted analysesin selectedareas where no current publisheddataexists. Overall,the goalof this articleis to providea basis fordistinguishingbetweenthesethreeimportantclinicalconditionsinolderadultsandshowinghowuseofseparate, distinct definitions of each can improve our understanding of the problems affecting older patients and lead to development of improved strategies for diagnosis, care, research, and medical education in this area.
3,394 citations
"The I.A.N.A. task force on frailty ..." refers background in this paper
...They found a prevalence of frailty of 7% in the CHS (4317 community-dwelling adults aged 65 and over), 30% in the subgroup of 80 and older, and 28% in the WHAS (moderately to severe disabled population of 1002 community-dwelling women aged 65 and over) (16, 17, 18)....
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TL;DR: Among nondisabled older persons living in the community, objective measures of lower-extremity function were highly predictive of subsequent disability.
Abstract: Background Functional assessment is an important part of the evaluation of elderly persons. We conducted this study to determine whether objective measures of physical function can predict subsequent disability in older persons. Methods This prospective cohort study included men and women 71 years of age or older who were living in the community, who reported no disability in the activities of daily living, and who reported that they were able to walk one-half mile (0.8 km) and climb stairs without assistance. The subjects completed a short battery of physical-performance tests and participated in a follow-up interview four years later. The tests included an assessment of standing balance, a timed 8-ft (2.4-m) walk at a normal pace, and a timed test of five repetitions of rising from a chair and sitting down. Results Among the 1122 subjects who were not disabled at base line and who participated in the four-year follow-up, lower scores on the base-line performance tests were associated with a statisticall...
3,388 citations