Original Study - Brief Report| Volume 22, ISSUE 8, P1664-1669.e4, August 2021

Concurrent and Predictive Validity of FRAIL-NH in Hospitalized Older Persons: An Exploratory Study



      The FRAIL-NH was originally developed for frailty assessment of nursing home (NH) residents. We aimed to compare concurrent, predictive, and known-groups validity between FRAIL-NH and FRAIL, using the Frailty Index (FI) as gold standard reference. We also examined for ceiling effect of both measures in the detection of severe frailty.


      A secondary analysis of a prospective cohort study.

      Setting & Participants

      Older adults (mean age 89.4 years) hospitalized for an acute medical illness in a 1300-bed tertiary hospital.


      Baseline data on demographics, comorbidities, severity of illness, functional status, and cognitive status were gathered. We also captured outcomes of mortality, length of stay (LOS), institutionalization, and functional decline. For concurrent validity, we compared areas under the operating characteristic curves (AUCs) for both measures against the FI. For predictive validity, univariate analyses and multiple logistic regression were used to compare both measures against the adverse outcomes of interest. For known-groups validity, we compared both measures against comorbidities and functional status via 1-way analysis of variance, and dementia diagnosis via independent t test. Box plots were also derived to investigate for possible ceiling effect.


      Both measures had good concurrent validity (both AUC > 0.8 and P < .001), with FRAIL-NH detecting more frailty cases (79.5% vs 50.0%). Although FRAIL-frail was superior for in-hospital mortality [6.7% vs 1.0%, P = .031, odds ratio (OR) 9.29, 95% confidence interval (CI) 1.09-79.20, P < .042] and LOS (10 vs 8 days, P = .043), FRAIL-NH-frail better predicted mortality (OR 6.62, 95% CI 1.91-22.94, P = .003) and institutionalization (OR 6.03, 95% CI 2.01-18.09, P = .001) up to 12 months postenrollment. Known-groups validity was good for both measures with FRAIL-NH yielding greater F values for functional status and dementia. Lastly, box plots revealed a ceiling effect for FRAIL in the severely frail group.

      Conclusions and Implications

      This exploratory study highlights the potential for expanding the role of FRAIL-NH beyond NH to acute care settings. Contrasted to FRAIL, FRAIL-NH had better overall validity with less ceiling effect in discrimination of severe frailty.


      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


        • Fried L.P.
        • Tangen C.M.
        • Walston J.
        • et al.
        Frailty in older adults: evidence for a phenotype.
        J Gerontol Med Sci. 2001; 56: M146-M156
        • 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
        • Dent E.
        • Lien C.
        • Lim W.S.
        • et al.
        The Asia-Pacific clinical practice guidelines for the management of frailty.
        J Am Med Dir Assoc. 2017; 18: 564-575
        • Cesari M.
        • Calvani R.
        • Marzetti E.
        Frailty in older persons.
        Clin Geriatr Med. 2017; 33: 293-303
        • Theou O.
        • Squires E.
        • Mallery K.
        • et al.
        What do we know about frailty in the acute care setting? A scoping review.
        BMC Geriatr. 2018; 18: 139
        • Lim S.H.
        • Ang S.Y.
        • Abu Bakar Aloweni F.B.
        • Østbye T.
        An integrative review on screening for frailty in acute care: Accuracy, barriers to implementation and adoption strategies.
        Geriatr Nurs. 2019; 40: 603-613
        • Jones D.M.
        • Song X.
        • Rockwood K.
        Operationalizing a frailty index from a standardised comprehensive geriatric assessment.
        J Am Geriatr Soc. 2004; 52: 1929-1933
        • Morley J.E.
        • Malmstrom T.K.
        • Miller D.K.
        A simple frailty questionnaire (FRAIL) predicts outcomes in middle aged African Americans.
        J Nutr Health Aging. 2012; 16: 601-608
        • Thompson M.Q.
        • Theou O.
        • Tucker G.R.
        • et al.
        FRAIL scale: Predictive validity and diagnostic test accuracy.
        Australas J Ageing. 2020; 39: e529-e536
        • Chong E.
        • Ho E.
        • Baldevarona-Llego J.
        • et al.
        Frailty in hospitalized older adults: Comparing different frailty measures in predicting short- and long-term patient outcomes.
        J Am Med Dir Assoc. 2018; 19: 450-457
        • Kaehr E.W.
        • Pape L.C.
        • Malmstrom T.K.
        • Morley J.E.
        FRAIL-NH predicts outcomes in long term care.
        J Nutr Health Aging. 2016; 20: 192-198
        • Kaehr E.
        • Visvanathan R.
        • Malmstrom T.K.
        • Morley J.E.
        Frailty in nursing homes: The FRAIL-NH Scale.
        J Am Med Dir Assoc. 2015; 16: 87-89
        • Theou O.
        • Tan E.C.K.
        • Bell J.S.
        • et al.
        Frailty levels in residential aged care facilities measured using the Frailty Index and FRAIL-NH scale.
        J Am Geriatr Soc. 2016; 64: e207-e212
        • Zhang X.
        • Dou Q.
        • Zhang W.
        • et al.
        Frailty as a predictor of all-cause mortality among older nursing home residents: A systematic review and meta-analysis.
        J Am Med Dir Assoc. 2019; 20: 657-663.e4
        • Searle S.D.
        • Rockwood K.
        What proportion of older adults in hospital are frail?.
        Lancet. 2018; 391: 1751-1752
        • 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
        • Charlson M.E.
        • Pompei P.
        • Ales K.L.
        • MacKenzie C.R.
        A new method of classifying prognostic comorbidity in longitudinal studies: development and validation.
        J Chronic Dis. 1987; 40: 373-383
        • Rockwood K.
        • Song X.
        • MacKnight C.
        • et al.
        A global clinical measure of fitness and frailty in elderly people.
        CMAJ. 2005; 173: 489-495
        • Wong W.C.
        • Sahadevan S.
        • Ding Y.Y.
        • et al.
        Resource consumption in hospitalised, frail older patients.
        Ann Acad Med Singap. 2010; 39: 830-836
        • Katz S.
        Assessing self-maintenance: Activities of daily living, mobility and instrumental activities of daily living.
        J Am Geriatr Soc. 1983; 31: 721-727
        • Sahadevan S.
        • Lim P.P.
        • Tan N.J.
        • Chan S.P.
        Diagnostic performance of two mental status tests in the older Chinese: Influence of education and age on cut-off values.
        Int J Geriatr Psychiatry. 2000; 15: 234-241
        • Inouye S.K.
        • van Dyck C.H.
        • Alessi C.A.
        • et al.
        Clarifying confusion: The confusion assessment method. A new method for detecting delirium.
        Ann Intern Med. 1990; 113: 941-948
        • Gobbens R.J.J.
        • van Assen M.A.L.M.
        • Luijkx K.G.
        • et al.
        The Tilburg Frailty Indicator: Psychometric properties.
        J Am Med Dir Assoc. 2010; 11: 344-355
        • Si H.
        • Jin Y.
        • Qiao X.
        • et al.
        Comparing diagnostic properties of the FRAIL-NH Scale and 4 frailty screening instruments among Chinese institutionalized older adults.
        J Nutr Health Aging. 2020; 24: 188-193
        • Jayanama K.
        • Theou O.
        • Blodgett J.M.
        • et al.
        Frailty, nutrition-related parameters, and mortality across the adult age spectrum.
        BMC Med. 2018; 16: 188
        • Badosa E.L.
        • Tahull M.B.
        • Casas N.V.
        • et al.
        Hospital malnutrition screening at admission: malnutrition increases mortality and length of stay.
        Nutr Hosp. 2017; 34: 907-913
        • Morley J.E.
        Editorial: Oral frailty.
        J Nutr Health Aging. 2020; 24: 683-684
        • Tanaka T.
        • Takahashi K.
        • Hirano H.
        • et al.
        Oral frailty as a risk factor for physical frailty and mortality in community-dwelling elderly.
        J Gerontol A Biol Sci Med Sci. 2018; 73: 1661-1667
        • van der Vorst A.
        • Op Het Veld L.P.M.
        • De Witte N.
        • et al.
        The impact of multidimensional frailty on dependency in activities of daily living and the moderating effects of protective factors.
        Arch Gerontol Geriatr. 2018; 78: 255-260
        • Liu Z.
        • Zhong G.
        • Li S.
        • et al.
        Use of serum albumin and activities of daily living to predict mortality in long-lived individuals over 95 years of age: a population-based study.
        Age (Dordr). 2015; 37: 9809
        • Chong E.
        • Chan M.
        • Lim W.S.
        • Ding Y.Y.
        Frailty predicts incident urinary incontinence among hospitalized older adults: A 1-year prospective cohort study.
        J Am Med Dir Assoc. 2018; 19: 422-427
        • Greco G.I.
        • Noale M.
        • Trevisan C.
        • et al.
        Increase in frailty in nursing home survivors of COVID-19: comparison with non-infected residents.
        J Am Med Dir Assoc. 2021; 22: 943-947.e3