key: cord-0783829-xy1xxjj2 authors: Huang, Emma Yun‐zhi; Lam, Simon Ching title: Review of frailty measurement of older people: Evaluation of the conceptualization, included domains, psychometric properties, and applicability date: 2021-09-19 journal: Aging Med (Milton) DOI: 10.1002/agm2.12177 sha: 3bb3dc6c2f3a45523358aa0288e3aea3fb9e75d5 doc_id: 783829 cord_uid: xy1xxjj2 The purposes of this review are to describe the existing research on frailty measurement of older people and to understand their characteristics, with a focus on conceptual definitions, psychometric properties, and diagnostic accuracies. We reviewed the published literature to explore if cross‐cultural studies of different types of frailty measurements have been conducted and to determine their applicability in the community setting. Narrative review with limited electronic database search and cross reference searching of included studies was performed. Studies published after year 2001 were searched for using MEDLINE and CINAHL Plus databases with keywords. A total of 5144 search results were obtained, but only 42 frailty measurements were identified in 68 studies. For the type, three different measurements were indicated, namely, self‐report instrument (n = 17), clinical observation assessment (n = 19), and mixed frailty assessment instrument (n = 6). Only 12 (29%) measurements examined reliability and validity. Nevertheless, over 35% did not perform any psychometric testing before applying. For diagnosis accuracies, 35 (83%) frailty measurements reported the cut‐off value(s) for determining level of the frailty. However, the sensitivity (56%‐89.5%) and specificity (52%‐91.3%) varied. The applicability was also diverse and some frailty instruments should be only used in some specific population and mode of administration. This review provides an overview of three major types of frailty measurements used in different settings with different purposes. For estimating the prevalence of frailty of older people in a community, the self‐report type may be appropriate. The psychometric properties of many reviewed instruments are reported insufficiently. The cut‐off value(s) are usually suggested with diverse sensitivity and specificity. Self‐report instruments, such as Groningen Frailty Indicator (GFI) and Tilburg Frailty Indicator (TFI), are the most extensively examined in terms of satisfactory psychometric properties. Thus, GFI and TFI, with the current evidence, are recommended to be used in the community setting for frailty screening tools. Frailty is widely noted as a status of increased vulnerability to stressors and reduced physiologic reserves and resilience of a person, more likely for an older person. 1 We are currently facing a progressive and an exponential aging population over the past decades. Furthermore, the demographic phenomenon of an absolute and a relative increased number of old and very old population is expected to continue for the coming 30 years. An accumulating evidence proves that due to the rapid growth of an aging population, frailty may become one of the most serious health issues in the world. 1 It is a multi-dimensional geriatric condition often known to be caused by cumulative cellular damage over one's life course. In addition, it has been proven to be one of the leading causes of premature mortality and morbidity for older people. 2 Moreover, frailty leads to high risk of negative health outcomes. With advancing age, the occurrence of frailty increases incrementally and shows a gender imbalance, occurring more often in women than in men, and a social class imbalance, occurring more often in those with a low socio-economic status. Older frail people are at high risk of adverse health outcomes, such as falls, morbidity, institutionalization, hospitalization, dependency, and mortality. [3] [4] [5] Approximately 3%-5% of mortality among older people can be delayed if frailty is prevented. 6 In addition, frailty profoundly influences the longevity of community-dwelling older people and impacts their quality of life by inducing functional decline. [6] [7] [8] Estimating the prevalence of frailty in a population is clearly one of the heterogeneous ways of measuring frailty, which provides a partial vision of the phenomenon. As expected, the aging society substantially contributes to the growing prevalence of frailty. A systematic review on 21 studies has indicated that frailty is not only common among western and developed countries but also in high prevalence in developing countries. At some point, the prevalence of frailty was at a wide range from 4% to 59.1%, and a difference between countries was noted. 9 Considering the weight of clinical conditions when measuring the prevalence of frailty is important, the prevalence of frailty can be different from clinical settings because of the common sense that a sicker person is more likely to be frail when using an independent instrument to assess it. Given the high prevalence of frailty and related burden of adverse health outcomes for frail older people, the early identification of frailty, especially for community-dwelling older people, should be the priority in primary care network. The concept of frailty is close to resilience, which is described as the ability to adapt when a traumatic life stressor suddenly occurs in a human. A meta-analysis of association of frailty and mortality in patients with Coronavirus disease 2019 has demonstrated that it is a significant association between frailty status and higher odds of mortality in patients of Using the theoretical resilience for explaining, a poorly resilient individual (a frail COVID-19 patient) will struggle to restore than to a non-frail one. The early diagnosis of frailty is essential in promoting a novel and comprehensive approach to older people and in integrating necessary healthcare service, especially when a worldwide public health event suddenly happen like COVID-19. Although the early identification of frailty is important, frailty management has not received adequate attention in gerontological nursing practice. Healthcare interventions for ameliorating or improving this condition have been scarcely researched. Some studies have even indicated that nurses cannot recognize frailty among the older population. 9 The inadequate attention to frailty management among the older population may be related to the confusion surrounding the phenomenon of frailty itself. First, no internationally recognized definition of frailty exists, and it is not easily recognized by older people themselves. 1 Second, although frailty has been proven to be one of the leading causes of premature mortality and morbidity for older people, some reports in literature characterize frailty as a protective bodily response to prevent the overtaxing of functional reserve. 1, 6 All of these inconsistencies may affect the proper assessment of symptoms and add difficulties to the recognition and management of the condition. In another aspect, if we consider the high prevalence ratio of frailty, then its prevention in older people seems to be cost-effective, especially in developing countries with large populations. Screening and early detection of frailty and its correlated factors should be a key concern. Twelve systematic reviews regarding frailty measurements have been published to date. Some of them are focused on the validation of frailty evaluation instruments, others aim for the clinimetric properties of instruments. However, most of these reviews are for clinical and primary care settings. One review has determined the diagnostic test accuracy of community-dwelling older people, mentioning that many kinds of self-reported frailty measurements exist in the world by now, such as Groningen Frailty Indicator (GFI), Edmonton Frailty Scale (EFS), and Tilburg Frailty Indicator (TFI). [10] [11] [12] Although four reviews of frailty measurements have addressed validation aspects, only one has tackled the psychometric properties of instruments for the detection of the frailty syndrome. Furthermore, none of them have provided comprehensive information and comparison data on the conceptual definitions, psychometric properties, and diagnostic accuracies of frailty measurement. 2, 13 How many frailty measurement tools are available? How about their quality and operation? In China, older people aged over 60 accounts for 18.70% of the total population from the updated data in 2021. Considering the prevalence of frailty and the adverse events due to the frailty syndrome in existing literature, the demand for the knowledge of frailty measurement tools or the community-dwelling K E Y W O R D S conceptual definitions, diagnostic accuracies, frailty measurements, instruments, older people, psychometric properties setting is high. Furthermore, the choice of researchers for frailty instruments should be guided by the issues related to the translation and validation for different locations and contexts. Therefore, the purposes of this review are to provide a comprehensive overview of comparison data about frailty measurement tools and to identify what frailty measurement tools are measured and whether they are used in the community-dwelling setting. Specifically, the research question of this review is which frailty measurement tools can be applied in the community-dwelling setting to assess the frailty of older people in China? It (a) examines international research on frailty measurement among older people; (b) presents the names, response modalities, domains, processes of instrumentation, and psychometric properties of frailty measurements; (c) highlights the needs of an evidence about which frailty measurement is appropriate for screening frailty in the community older population in China. 3 Potential relevant articles were identified by screening titles and abstracts against the following inclusion criteria. Only full-text academic journals were considered. Secondary search was also performed on the basis of the citation of the reference list of potentially relevant articles, if necessary. The following inclusion criteria for selecting relevant studies were used: • The study sample was older people (age ≥65 years old). • The study aimed to develop a quantitative frailty measurement. • The measurement is preferred with frailty classification or frailty prognosis as a kind of outcome prediction. Frailty measurements were reviewed, tabulated, and discussed using the following standards: • Nature of the measurement (ie, description of item generation, conceptual definition of frailty, and target population). • Included domains (ie, physical, psychological, social, and cognitive) • Response modalities and scoring (ie, number of items, response format, and scoring method). • Psychometric properties (ie, reliability, validity, and diagnostic accuracy). • Operation of the measurement (ie, time of completion, way of administration, requirement of special device(s) or training and applicable setting). A total of 5144 relevant studies were found. Through the application of the above inclusion criteria, 475 full text articles were eligible. Two researchers independently finished data extraction from every eligible paper. We included English-language studies that met the three inclusion criteria. We excluded studies that did not examine frailty measurements used for older people. All disagreements of the two researchers were resolved with consensus. Finally, only 42 frailty measurements were identified in 68 studies ( Figure 1 ). The suitability of the studies included studies was evaluated in terms of the two researchers' agreement with the search string. Table 1 presents the detailed information about the names, response modalities, domains, processes of instrumentation, and psychometric properties of the reviewed measurements. Major findings from the included articles were compared one to another for similarities and differences. Although no consensual definition of frailty is identified, the literature in general indicates that frailty is of multidimensional nature and associates with geriatric syndrome. Reducing morbidity, quality of life, and cognitive function of older people is important, and the definition of frailty has gained the attention of many scholars worldwide. [14] [15] [16] [17] How the frailty is defined as an important issue for geriatric studies. The earliest definition of frailty is "a decrease in physiologic reserve and an increase in probability of disability." 18 However, no consensual definition of frailty exists to date. As mentioned, no international agreed definition of frailty exists until now, leading to various definitions worldwide. Hence, identifying the domains that contribute to frailty is difficult. Researchers have begun to consider that frailty is of multidimensional nature. [27] [28] [29] [30] [31] Numerous studies have started investigating and reviewing the "domains contributing to frailty." A review of 17 different definitions of frailty has concluded that the common contributing domains can be grouped into physical, cognitive, psychological, nutritional, social, aging, and disease domains. 1 Another well-accepted study has found more domains contributed to frailty, including strength, nutrition, endurance, mobility, physical activity, balance, cognition, sensory function (hearing, visual acuity), mood (depressive functions, anxiety), coping, social relations, and social support. 21 Other researchers have added that sociodemographic domains, such as living alone, poverty, low education and area deprivation, polypharmacy domains, diseases (cancer, endocrine disorders, dementia) and their associated complications, and low physical activity, should also be considered when defining frailty. [32] [33] [34] [35] Frailty serves as a conceptual basis of a heath-based, integrative approach. 36 Taking the WHO concept of health as "a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity," Gobbens et al defined frailty with human functioning losses of one or more domains of "Physical," "Psychological" and "Social." 21 Those mentioned above in different studies can almost be grouped into these three domains; for example, aging, disease, nutritional, strength, endurance, mobility, physical activity, polypharmacy, balance, and sensory function may be grouped into physical domains [37] [38] [39] [40] [41] [42] ; social relations and support, poverty, low education, area deprivation, and living alone may be grouped into social domains [43] [44] [45] [46] [47] ; coping and mood may be grouped into psychological domains [48] [49] [50] ; but cognitive may not be grouped into psychological domains or any of the two other domains. In 2013, the International Academy of Nutrition and Aging (IANA) and IAGG held a meeting in France about the rational and definition of "cognitive Frailty;" it emphasized that human functioning frailty coexists with cognitive impairment. 51 Such meeting intentionally included cognitive function as one of the major domains in shaping frailty. In conclusion, frailty was comprehensively shaped by these four recommended domains, which are physical, psychological, social, and cognitive aspects. Psychometric properties in measuring older people Of the 5144 relevant studies, 42 frailty measurements were identified. For the type, three different measurements were indicated, namely, self-report instrument (n = 17), clinical observation assessment (n = 19), and mixed frailty assessment instrument (n = 6). The self-reporting type was mainly applied for screening community older people. The latter two were used for older patients in clinical or institutionalized settings. Table 2 . This thorough review of studies about frailty measurements on older people provides a comprehensive picture of frailty measurements. We are the first studies evaluating and grouping the types of frailty measurement that facilitated the appropriate application in different research. Although no international definition of frailty and no inter- Psychometric properties in measuring older people Fried's Frailty Phenotype-Cardiovascular Health Study Index (CHS) ✓ ✗ ✓ ✓ 6 ✗ Kihon Checklist (KCL) ✗ ✗ ✗ ✓ 25 ✓ Handgrip Strength (HS) ✗ ✗ ✓ ✓ 1 ✓ Multidimensional Prognostic Instrument (MPI) ✗ ✗ ✗ ✓ 8 ✗ PRISMA-7 questionnaire ✓ ✗ ✗ ✓ 7 ✗ Puts' Instrument ✗ ✗ ✗ ✗ 9 ✗ Ravaglia's Instrument ✗ ✗ ✗ ✗. 9 ✗ Rothman's Instrument ✗ ✗ ✗ ✗ 7 ✗ (Continues) As stated above, frailty measurements have three main types. 56 First is the self-report frailty instrument, which allows the collection of a large amount of data to well estimate the prevalence of frailty in the community setting because of the nature of self-reporting. Approximately 41% of identified instruments (eg, GFI, 57 Considering the rapid aging population problem in the whole world, a fast and valid frailty measurement for frailty prevalence screening on older people is effective, particularly for developing countries with large population. However, the world's most commonly used frailty measurement with high validity and reliability is Frailty Index, 69 which is clinically used and time-consuming and thus cannot be easily used for cross-sectional large-population prevalence research. [70] [71] [72] [73] Hence, self-reported frailty measurements are needed to be tested in different cultures of older people; their testing diagnosis accuracies must also be determined before use. [74] [75] [76] Moreover, geriatric researchers must agree on a brief, effective frailty measurement, which can help establish an international or a gold standard of frailty measurement in the future. 77 We performed a narrative review, which lacks, rigorous search methodology, quality assessment, an analysis and quality appraisal section, synthesis methods of searching results, and reports of risks or biases of a systematic review. We think that a formal COSMIN systematic review should be important to expand our work once the gold criteria of frailty are developed. 70 This review reveals the three major types of frailty measurements used in different settings with different purposes. For estimating the frailty of older people in the community setting, the self-report type may be appropriate. The psychometric properties are reported insufficiently. The cut-off value(s) are usually suggested with diverse sensitivity and specificity. National health departments and nursing homes or medical care centers for older people should pay greater attention to frailty. The authors declare no conflict of interest to disclose regarding the publication of this article. Emma Yun-zhi HUANG conceived the idea of this narrative review, and designed, conducted the study and drafted the manuscript. Simon Ching LAM was the secondary reviewer of this narrative review and involved with screening, data analysis, and provided important intellectual facts to revise the manuscript. The authors wish to thank Dr. Si-yang Ye and Ms. Percy Wing Tung Ho for their help for literature searching. 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