Update on Frailty Original Article| Volume 19, ISSUE 4, P310-314.e3, April 2018

Comparison of 3 Frailty Instruments in a Geriatric Acute Care Setting in a Low-Middle Income Country

Published:December 27, 2017DOI:



      Comparison of frailty instruments in low-middle income countries, where the prevalence of frailty may be higher, is scarce. In addition, less complex diagnostic tools for frailty are important in these settings, especially in acutely ill patients, because of limited time and economic resources. We aimed to compare the performance of 3 frailty instruments for predicting adverse outcomes after 1 year of follow-up in older adults with an acute event or a chronic decompensated disease.


      Prospective cohort study.


      Geriatric day hospital (GDH) specializing in acute care.


      A total of 534 patients (mean age 79.6 ± 8.4 years, 63% female, 64% white) admitted to the GDH.


      Frailty was assessed using the Cardiovascular Health Study (CHS) criteria, the Study of Osteoporotic Fracture (SOF) criteria, and the FRAIL (fatigue, resistance, ambulation, illnesses, and loss of weight) questionnaire. Monthly phone contacts were performed over the course of the first year to detect the following outcomes: incident disability, hospitalization, fall, and death. Multivariable Cox proportional hazard regression models were performed to evaluate the association of the outcomes with frailty as defined by the 3 instruments. In addition, we compared the accuracy of these instruments for predicting the outcomes.


      Prevalence of frailty ranged from 37% (using FRAIL) to 51% (using CHS). After 1 year of follow-up, disability occurred in 33% of the sample, hospitalization in 40%, fall in 44%, and death in 16%. Frailty, as defined by the 3 instruments was associated with all outcomes, whereas prefrailty was associated with disability, using the SOF and FRAIL instruments, and with hospitalization using the CHS and SOF instruments. The accuracy of frailty to predict different outcomes was poor to moderate with area under the curve varying from 0.57 (for fall, with frailty defined by SOF and FRAIL) to 0.69 (for disability, with frailty defined by CHS).


      In acutely ill patients from a low-middle income country GDH acute care unit, the CHS, SOF, and FRAIL instruments showed similar performance in predicting adverse outcomes.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of the American Medical Directors Association
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Clegg A.
        • Young J.
        • Iliffe S.
        • et al.
        Frailty in elderly people.
        Lancet. 2013; 381: 752-762
        • Da Mata F.A.
        • Pereira P.P.
        • Andrade K.R.
        • et al.
        Prevalence of frailty in Latin America and the Caribbean: A systematic review and meta-analysis.
        PLoS One. 2016; 11: e0160019
        • Bandeen-Roche K.
        • Seplaki C.L.
        • Huang J.
        • et al.
        Frailty in older adults: A nationally representative profile in the United States.
        J Gerontol A Biol Sci Med Sci. 2015; 70: 1427-1434
        • Theou O.
        • Brothers T.D.
        • Rockwood M.R.
        • et al.
        Exploring the relationship between national economic indicators and relative fitness and frailty in middle-aged and older Europeans.
        Age Ageing. 2013; 42: 614-619
        • Collard R.M.
        • Boter H.
        • Schoevers R.A.
        • Oude Voshaar R.C.
        Prevalence of frailty in community-dwelling older persons: A systematic review.
        J Am Geriatr Soc. 2012; 60: 1487-1492
        • Kojima G.
        Prevalence of frailty in nursing homes: A systematic review and meta-analysis.
        J Am Med Dir Assoc. 2015; 16: 940-945
        • Verlaan S.
        • Ligthart-Melis G.C.
        • Wijers S.L.J.
        • et al.
        High prevalence of physical frailty among community-dwelling malnourished older adults–A systematic review and meta-analysis.
        J Am Med Dir Assoc. 2017; 18: 374-382
        • Dent E.
        • Kowal P.
        • Hoogendijk E.O.
        Frailty measurement in research and clinical practice: A review.
        Eur J Intern Med. 2016; 31: 3-10
        • Fried L.P.
        • Tangen C.M.
        • Walston J.
        • et al.
        Frailty in older adults: Evidence for a phenotype.
        J Gerontol A Biol Sci Med Sci. 2001; 56: M146-M156
        • Buta B.J.
        • Walston J.D.
        • Godino J.G.
        • et al.
        Frailty assessment instruments: Systematic characterization of the uses and contexts of highly cited instruments.
        Ageing Res Rev. 2016; 26: 53-61
        • Abellan van Kan G.
        • Rolland Y.M.
        • Morley J.E.
        • Vellas B.
        Frailty: Toward a clinical definition.
        J Am Med Dir Assoc. 2008; 9: 71-72
        • Ensrud K.E.
        • Ewing S.K.
        • Taylor B.C.
        • et al.
        Comparison of 2 frailty indexes for prediction of falls, disability, fractures, and death in older women.
        Arch Intern Med. 2008; 168: 382-389
        • Ensrud K.E.
        • Ewing S.K.
        • Cawthon P.M.
        • et al.
        A comparison of frailty indexes for the prediction of falls, disability, fractures, and mortality in older men.
        J Am Geriatr Soc. 2009; 57: 492-498
        • Roppolo M.
        • Mulasso A.
        • Gobbens R.J.
        • et al.
        A comparison between uni- and multidimensional frailty measures: Prevalence, functional status, and relationships with disability.
        Clin Interv Aging. 2015; 10: 1669-1678
        • Theou O.
        • Brothers T.D.
        • Mitnitski A.
        • Rockwood K.
        Operationalization of frailty using eight commonly used scales and comparison of their ability to predict all-cause mortality.
        J Am Geriatr Soc. 2013; 61: 1537-1551
        • Woo J.
        • Leung J.
        • Morley J.E.
        Comparison of frailty indicators based on clinical phenotype and the multiple deficit approach in predicting mortality and physical limitation.
        J Am Geriatr Soc. 2012; 60: 1478-1486
        • Malmstrom T.K.
        • Miller D.K.
        • Morley J.E.
        A comparison of four frailty models.
        J Am Geriatr Soc. 2014; 62: 721-726
        • Ravindrarajah R.
        • Lee D.M.
        • Pye S.R.
        • et al.
        The ability of three different models of frailty to predict all-cause mortality: Results from the European Male Aging Study (EMAS).
        Arch Gerontol Geriatr. 2013; 57: 360-368
        • Nguyen T.N.
        • Cumming R.G.
        • Hilmer S.N.
        A review of frailty in developing countries.
        J Nutr Health Aging. 2015; 19: 941-946
        • Gray W.K.
        • Richardson J.
        • McGuire J.
        • et al.
        Frailty Screening in low- and middle-income countries: A systematic review.
        J Am Geriatr Soc. 2016; 64: 806-823
        • Aliberti M.J.
        • Suemoto C.K.
        • Fortes-Filho S.Q.
        • et al.
        The geriatric day hospital: Preliminary data on an innovative model of care in Brazil for older adults at risk of hospitalization.
        J Am Geriatr Soc. 2016; 64: 2149-2153
        • Folstein M.F.
        • Folstein S.E.
        • McHugh P.R.
        “Mini-mental state”. A practical method for grading the cognitive state of patients for the clinician.
        J Psychiatr Res. 1975; 12: 189-198
        • Nunes D.P.
        • Duarte Y.A.
        • Santos J.L.
        • Lebrao M.L.
        Screening for frailty in older adults using a self-reported instrument.
        Rev Saude Publica. 2015; 49: 2
        • Benedetti T.R.B.
        • Antunes PdC.
        • Rodriguez-Añez C.R.
        • et al.
        Reprodutibilidade e validade do Questionário Internacional de Atividade Física (IPAQ) em homens idosos.
        Revista Brasileira de Medicina do Esporte. 2007; 13: 11-16
        • DeLong E.R.
        • DeLong D.M.
        • Clarke-Pearson D.L.
        Comparing the areas under two or more correlated receiver operating characteristic curves: A nonparametric approach.
        Biometrics. 1988; 44: 837-845
        • Drubbel I.
        • Numans M.E.
        • Kranenburg G.
        • et al.
        Screening for frailty in primary care: A systematic review of the psychometric properties of the frailty index in community-dwelling older people.
        BMC Geriatr. 2014; 14: 27
        • Widagdo I.S.
        • Pratt N.
        • Russell M.
        • Roughead E.E.
        Predictive performance of four frailty measures in an older Australian population.
        Age Ageing. 2015; 44: 967-972
        • Garcia-Pena C.
        • Avila-Funes J.A.
        • Dent E.
        • et al.
        Frailty prevalence and associated factors in the Mexican health and aging study: A comparison of the frailty index and the phenotype.
        Exp Gerontol. 2016; 79: 55-60
        • Wou F.
        • Gladman J.R.
        • Bradshaw L.
        • et al.
        The predictive properties of frailty-rating scales in the acute medical unit.
        Age Ageing. 2013; 42: 776-781
        • Chong E.
        • Ho E.
        • Baldevarona-Llego J.
        • et al.
        Frailty and risk of adverse outcomes in hospitalized older adults: A comparison of different frailty measures.
        J Am Med Dir Assoc. 2017; 18: 638.e7-638.e11
        • Morley J.E.
        • Vellas B.
        • van Kan G.A.
        • et al.
        Frailty consensus: A call to action.
        J Am Med Dir Assoc. 2013; 14: 392-397
        • Kiely D.K.
        • Cupples L.A.
        • Lipsitz L.A.
        Validation and comparison of two frailty indexes: The MOBILIZE Boston Study.
        J Am Geriatr Soc. 2009; 57: 1532-1539
        • Forti P.
        • Rietti E.
        • Pisacane N.
        • et al.
        A comparison of frailty indexes for prediction of adverse health outcomes in an elderly cohort.
        Arch Gerontol Geriatr. 2012; 54: 16-20
        • Joosten E.
        • Demuynck M.
        • Detroyer E.
        • Milisen K.
        Prevalence of frailty and its ability to predict in hospital delirium, falls, and 6-month mortality in hospitalized older patients.
        BMC Geriatr. 2014; 14: 1
        • Aprahamian I.
        • Lin S.M.
        • Suemoto C.K.
        • et al.
        Feasibility and factor structure of the FRAIL scale in older adults.
        J Am Med Dir Assoc. 2017; 18: 367.e11-367.e18
        • Rosas-Carrasco O.
        • Cruz-Arenas E.
        • Parra-Rodriguez L.
        • et al.
        Cross-cultural adaptation and validation of the FRAIL scale to assess frailty in Mexican adults.
        J Am Med Dir Assoc. 2016; 17: 1094-1098