Utility of the Fatigue, Resistance, Ambulation, Illness, and Loss of weight Scale in Older Patients with Cardiovascular Disease

Published:September 19, 2022DOI:



      To compare the Fried criteria for frailty diagnosis with the Frailty Screening Index (FSI) and the fatigue, resistance, ambulation, illness, and loss of weight (FRAIL) scale in older patients with cardiovascular disease (CVD).


      We conducted a retrospective 1-year follow-up cohort study of adult inpatients who participated in a cardiac rehabilitation program between June 2016 and September 2018.

      Setting and Participants

      We included 1472 Japanese patients age 65 years and older with CVD. After excluding 765 patients with incomplete frailty measurements, 707 patients were included in the analysis.


      Frailty and physical function were measured before hospital discharge according to each of the 3 definitions. Outcomes were all-cause mortality and physical dysfunction.


      The prevalence of frailty according to the Fried criteria, the FRAIL scale, and the FSI was 213 (30.1%), 181 (25.6%), and 186 (26.3%), respectively. The FSI and the FRAIL scale showed moderate agreement with the Fried criteria [vs FSI: K = 0.52, 95% confidence interval (CI): 0.45–0.59; vs FRAIL scale: K = 0.45, 95% CI: 0.37–0.52; all P < .001]. We found a significant correlation between all-cause mortality and frailty assessed by all of the definitions, even after multivariate adjustment [FSI: hazard ratio (HR): 2.43, 95% CI: 1.30–4.58, P = .006; FRAIL scale: HR: 2.32, 95% CI: 1.21–4.45, P = .011; Fried criteria: HR: 1.99, 95% CI: 1.04–3.82, P = .038). However, the prediction accuracy of the FRAIL scale was higher than that of the FSI and comparable to that of the Fried criteria for physical dysfunction.

      Conclusions and Implications

      The FSI and the FRAIL scale showed moderate agreement with the Fried criteria regarding frailty diagnostic performance and had comparable prognostic value. However, only the FRAIL scale was as accurate as the Fried criteria in screening for physical dysfunction.


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        • Kovacic J.C.
        • Moreno P.
        • Hachinski V.
        • et al.
        Cellular senescence, vascular disease, and aging part 1 of a 2-part review.
        Circulation. 2011; 123: 1650-1660
        • Heidenreich P.A.
        • Trogdon J.G.
        • Khavjou O.A.
        • et al.
        Forecasting the future of cardiovascular disease in the United States: s policy statement from the American Heart Association.
        Circulation. 2011; 123: 933-944
        • Afilalo J.
        • Alexander K.P.
        • Mack M.J.
        • et al.
        Frailty assessment in the cardiovascular care of older adults.
        J Am Coll Cardiol. 2014; 63: 747-762
        • Ferrucci L.
        • Fabbri E.
        Inflammageing: chronic inflammation in ageing, cardiovascular disease, and frailty.
        Nat Rev Cardiol. 2018; 15: 505-522
        • 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
        • Yamada M.
        • Arai H.
        Social frailty predicts incident disability and mortality among community-dwelling Japanese older adults.
        J Am Med Dir Assoc. 2018; 19: 1099-1103
        • Woo J.
        • Yu R.
        • Wong M.
        • et al.
        Frailty screening in the community using the frail scale.
        J Am Med Dir Assoc. 2015; 16: 412-419
        • Ando Y.
        • Ito S.
        • Uemura O.
        • et al.
        CKD clinical practice guidebook. The essence of treatment for CKD patients.
        Clin Exp Nephrol. 2009; 13: 191-248
        • 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
        • Yamada M.
        • Arai H.
        Predictive value of frailty scores for healthy life expectancy in community-dwelling older Japanese adults.
        J Am Med Dir Assoc. 2015; 16: 1002.e7-1002.e11
        • Morley J.E.
        • Malmstrom T.K.
        • Miller D.K.
        A simple frailty questionnaire (frail) predicts outcome in middle aged African Americans.
        J Nutr Health Aging. 2012; 16: 601-608
        • Kamiya K.
        • Masuda T.
        • Tanaka S.
        • et al.
        Quadriceps Strength as a Predictor of Mortality in Coronary Artery Disease.
        Am J Med. 2015; 128: 1212-1219
      1. ATS statement: guidelines for six-minute walk test.
        Am J Respir Crit Care Med. 2002; 166: 111-117
        • Guralnik J.M.
        • Simonsick E.M.
        • Ferrucci L.
        • et al.
        A short physical performance battery assessing lower extremity function: association with self-reported disability and prediction of mortality and nursing home admission.
        J Gerontol. 1994; 49: M85-M94
        • Schafer J.
        • Strimmer K.
        A shrinkage approach to large-scale covariance matrix estimation and implications for functional genomics.
        Stat Appl Genet Mol Biol. 2005; 4: 32
        • Metra M.
        • Ponikowski P.
        • Dickstein K.
        • et al.
        Advanced chronic heart failure: a position statement from the study group on advanced heart failure of heart failure Association of the European Society of Cardiology.
        Eur J Heart Fail. 2007; 9: 684-694
        • Fang J.C.
        • Ewald G.A.
        • Allen L.A.
        • et al.
        Advanced (stage a) heart failure: a statement from the Herat Failure Society of America Guidelines Committee.
        J Card Fail. 2015; 21: 519-534
        • Newman A.B.
        • Simonsick E.M.
        • Naydeck B.L.
        • et al.
        Association of long-distance corridor walk performance with mortality, cardiovascular disease, mobility limitation, and disability.
        JAMA. 2006; 295: 2018-2026
        • Vasunilashorn S.
        • Coppin A.K.
        • Patel K.V.
        • et al.
        Use of the short physical performance battery score to predict loss of ability to walk 400 meters: analysis from the InCHIANTI Study.
        J Gerontol A Bio Sci Med Sci. 2009; 64: 22-229
        • 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
        • Wong T.Y.
        • Massa M.S.
        • O’Halloran A.M.
        • et al.
        Cardiovascular risk factors and frailty in a cross-sectional study of older people: implications for prevention.
        Age Aging. 2018; 47: 714-720
        • Afilalo J.
        frailty in patients with cardiovascular disease: why, when, and how to measure.
        Curr Cardiovasc Risk Rep. 2011; 5: 467-472
        • Skender S.
        • Ose J.
        • Chang-Claude J.
        • et al.
        Accelerometry and physical activity questionnaires: a systematic review.
        BMC Public Health. 2016; 16: 515
        • Schmidt C.
        • Santos M.
        • Bohn L.
        • et al.
        Comparison of questionnaire and accelerometer-based assessments of physical activity in patients with heart failure with preserved ejection fraction: clinical and prognostic implications.
        Scand Cardiovasc J. 2020; 54: 77-83
        • Duchnowski P.
        • Szymanski P.
        • Kusmierczyk M.
        • et al.
        Usefulness of FRAIL Scale in Heart Valve Diseases.
        Clin Interv Aging. 2020; 15: 1071-1075
        • Ivan A.
        • Natália O.C.C.
        • Rafael I.
        • et al.
        Screening for frailty with the FRAIL Scale: a comparison with the phenotype criteria.
        J Am Med Dir Assoc. 2017; 18: 592-596
        • Chen S.
        • Honda T.
        • Narazaki K.
        • et al.
        Physical frailty and risk of needing long-term care in community-dwelling older adults: a 6-year prospective study in Japan.
        J Nutr Health Aging. 2019; 23: 856-861
        • Nozaki K.
        • Kamiya K.
        • Hamazaki N.
        • et al.
        Validity and utility of questionnaire-based FRAIL scale in older patients with heart failure: findings from the FRAGILE-HF.
        J Am Med Dis Assoc. 2021; 22: 1621-1626
        • Yamada M.
        • Kimura Y.
        • Ishiyama D.
        • et al.
        Effect of the COVID-19 epidemic on physical activity in community-dwelling older adults in Japan: a cross-sectional online survey.
        J Nutr Health Aging. 2020; 24: 948-950
        • Robinson E.
        • Boyland E.
        • Chisholm A.
        • et al.
        Obesity, eating behavior and physical activity during COVID-19 lockdown: a study of UK adults.
        Appetite. 2021; 156: 1-7
        • Stockwell S.
        • Trott M.
        • Tully M.
        • et al.
        Changes in physical activity and sedentary behaviours from before to during the COVID-19 pandemic lockdown: a systematic review.
        BMJ Open Sport Exerc Med. 2021; 7: e000960
        • Ma Y.
        • Hou L.
        • Yang X.
        • et al.
        The association between frailty and severe disease among COVID-19 patients aged over 60 years in China: a prospective cohort study.
        BMC Med. 2020; 18: 274
        • Kenneth R.
        • Xiaowei S.
        • Chris M.
        • et al.
        A global clinical measure of fitness and frailty in elderly people.
        CMAJ. 2005; 173: 489-495
        • Mitnitski A.B.
        • Mogilner A.J.
        • Rockwood K.
        Accumulation of deficits as a proxy measure of aging.
        Sci World J. 2001; 1: 323-336