JAMDA xxx (2015) 1e8
JAMDA journal homepage: www.jamda.com
Original Study
Frailty Screening in the Community Using the FRAIL Scale Jean Woo MD a, *, Ruby Yu PhD a, Moses Wong MPhil a, Fannie Yeung MSc a, Martin Wong BSc a, Christopher Lum FRCP b a b
Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong Department of Medicine and Geriatrics, Shatin Hospital, Hospital Authority, Hong Kong
a b s t r a c t Keywords: FRAIL scale sarcopenia mild cognitive impairment screening falls physical function
Objectives: To explore the feasibility of using the FRAIL scale in community screening of older Chinese people aged 65 years and older, followed by clinical validation by comprehensive geriatric assessment of those classified as pre-frail or frail. Design: Two-phase study: screening of people aged 65 years and older by trained volunteers, followed by comprehensive geriatric assessment by multidisciplinary staff for those classified as pre-frail or frail. Setting: Elderly Centers in the New Territories East Region of Hong Kong SAR China. Participants: A total of 816 members of elderly centers attending by themselves or accompanied by relatives. Measurements: For phase 1, questionnaire (including demographic, lifestyle, chronic diseases) and screening tools were administered by trained volunteers. These consist of the FRAIL scale, SARC-F to screen for sarcopenia, and mild cognitive impairment using the abbreviated screening for mild cognitive impairment (Abbreviated Memory Inventory for the Chinese). Blood pressure, body mass index, and grip strength were recorded. For phase 2, comprehensive geriatric assessment include questionnaires assessing lifestyle domain (physical activity, nutritional status using the Mini-Nutritional AssessmentShort Form), the physical domain (number of diseases and number of drugs, activities of daily living and instrumental activities of daily living disabilities, geriatric syndromes, self-rated health, sleep quality), cognitive and psychological domain (Mini-Mental State Examination, Geriatric Depression Scale), and social domain (income, housing, living satisfaction, family support). Results: The prevalence of pre-frailty and frailty were 52.4% and 12.5%, respectively. The prevalence for frailty increasing with age from 5.1% for those aged 65e69 years to 16.8% for those 75, being greater in women compared with men (13.9% vs 4.2%). Of those who were pre-frail or frail (n ¼ 529), 42.5% had sarcopenia and 60.7% had mild cognitive impairment. Among those who were frail (n ¼ 102), sarcopenia and mild cognitive impairment were also frequently present: 12.8% had sarcopenia, 14.7% had mild cognitive impairment, 63.7% had both sarcopenia and mild cognitive impairment, and only 8.8% had neither. In phase 2, participants who were classified as pre-frail or frail (n ¼ 529) were invited for further interviews; 255 participants (48.2%) returned. Compared with the pre-frail group, those in the frail group were less physically active, had higher number of chronic diseases, were taking more medications (more were taking sleeping pills), reported more falls, rated their health as poor, had higher prevalence of depressive symptoms and mild cognitive impairment, had higher prevalence of sarcopenia, and a high number of activities of daily living and instrumental activities of daily living disabilities. Conclusion: The FRAIL scale may be used as the first step in a step care approach to detecting frailty in the community, allowing targeted intervention to potentially retard decline and future disability. Ó 2015 AMDA e The Society for Post-Acute and Long-Term Care Medicine.
Frailty was developed over a decade ago as a concept describing the aging process as a biological/physiological state,1,2 one concept being a multiple deficit model1 whereas the other a description of a phenotype that excludes disability measures.2 Many epidemiological * Address correspondence to Jean Woo, Department of Medicine and Therapeutics, Prince of Wales Hospital, Shatin, N.T. Hong Kong. E-mail address: [email protected] (J. Woo). http://dx.doi.org/10.1016/j.jamda.2015.01.087 1525-8610/Ó 2015 AMDA e The Society for Post-Acute and Long-Term Care Medicine.
studies using either model have established the importance of the concept, as predicting many adverse health outcomes, quality of life, use of hospital services, and mortality, independent of diseases and disability. Recent literature have suggested that frailty may be divided into physical frailty represented by sarcopenia, and cognitive frailty represented by some degree of cognitive impairment (either the diagnosis of dementia or mild cognitive impairment).3e6 The close link with nutrition has also been described.7,8
2
J. Woo et al. / JAMDA xxx (2015) 1e8
In recent years research efforts have been directed towards the development of frailty screening tools suitable for use in the primary care setting, with a view to early identification followed by intervention to retard decline, particularly from the pre-frail to the frail category.9 Evidence shows that older people may move between different frailty states with time.10 Various consensus groups have emphasized the importance of incorporating frailty into practice,11,12 as well as national societies, nongovernment organizations, and think tanks.13 Various tools with varying items have been used in the primary care setting.2,14e17 A recent systematic review of the diagnostic test accuracy of simple instruments for identifying frailty in community-dwelling people concluded that no single test may be used because many have high sensitivity but low specificity.18 Among simple tools that have been used in the primary care setting, the FRAIL scale is short, consisting of 5 items (fatigue, resistance, ambulation, illnesses, and loss of weight) only, does not require measurements nor administration by healthcare professionals. Validity has been examined by comparing with the phenotypic and multiple deficit classifications.19 Recently, it has been used in a frailty survey in Ireland.20 Although many studies have been concerned with psychometric properties and validation with multidomain clinical assessments, few have explored its potential in the services setting or from a public health perspective. This study explores the feasibility of using the FRAIL scale in a community screening of older Chinese people aged 65 years and older, followed by clinical validation using comprehensive geriatric assessment of those classified as pre-frail or frail. Methods Study Population and Design Participants were mainly recruited from 3 districts in the New Territories East: Sha Tin, Tai Po, and North. The 3 districts had similar sociio-demographics with the rest of Hong Kong.21 An invitation letter was sent to elderly community centers, holiday centers for the elderly, neighborhood elderly centers, social centers for the elderly, offices of district councilor, owners’ corporations, and religious/ nonreligious organizations/societies in the 3 districts (95 units); 18 accepted. Community-dwelling older adults aged 65 years and older were invited to their affiliated centers for interview and assessment. Approval by the ethics committee of the Chinese University of Hong Kong was obtained. Written informed consent was obtained from all participants prior to the study. The study has a 2-phase design; phase 1 pertained to frailty screening assessment. Those who were classified as pre-frail or frail were invited for further comprehensive geriatric assessment at phase 2. For both phases of assessments, participants from whom information could not be directly obtained because of poor cognitive function or illness, their relatives and carers were interviewed instead. Phase 1: Frailty Screening The 5-item FRAIL scale was used for screening for frailty.22 There are 5 components: fatigue, resistance, ambulation, illnesses, and loss of weight. Frailty scores range from 0 to 5 (ie, 1 point for each component; 0 ¼ best to 5 ¼ worst) and represent frail (3e5), pre-frail (1e2), and robust (0) health status. Frailty screening assessment also included screening for sarcopenia using the SARC-F questionnaire23 and mild cognitive impairment using the Abbreviated Memory Inventory for the Chinese (AMIC).24 There are 5 components of SARC-F questionnaire: strength, assistance with walking, rise from a chair, climb stairs, and fall. The
SARC-F scores range from 0 to 10, with 0 to 2 points for each component. A score 4 is predictive of sarcopenia and poor outcomes. AMIC is an abbreviated version (5-item form) of the original 27-item Memory Inventory for the Chinese (validated for the diagnosis of mild cognitive impairment, with a sensitivity of 54.6%e65.3% and specificity of 57.4%).24 An AMIC score 3 is predictive of mild cognitive impairment. Demographics (age, sex, educational level, marital status) and lifestyle variables (smoking, alcohol intake) were obtained. Smoking status was divided into nonsmokers, ex-smokers, and current smokers. Alcohol intake was divided into 3 categories: nondrinkers, ex-drinkers, and current drinkers. Number of self-reported comorbidities was also assessed. Systolic and diastolic blood pressures were measured. Participants with systolic blood pressure
JAMDA journal homepage: www.jamda.com
Original Study
Frailty Screening in the Community Using the FRAIL Scale Jean Woo MD a, *, Ruby Yu PhD a, Moses Wong MPhil a, Fannie Yeung MSc a, Martin Wong BSc a, Christopher Lum FRCP b a b
Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong Department of Medicine and Geriatrics, Shatin Hospital, Hospital Authority, Hong Kong
a b s t r a c t Keywords: FRAIL scale sarcopenia mild cognitive impairment screening falls physical function
Objectives: To explore the feasibility of using the FRAIL scale in community screening of older Chinese people aged 65 years and older, followed by clinical validation by comprehensive geriatric assessment of those classified as pre-frail or frail. Design: Two-phase study: screening of people aged 65 years and older by trained volunteers, followed by comprehensive geriatric assessment by multidisciplinary staff for those classified as pre-frail or frail. Setting: Elderly Centers in the New Territories East Region of Hong Kong SAR China. Participants: A total of 816 members of elderly centers attending by themselves or accompanied by relatives. Measurements: For phase 1, questionnaire (including demographic, lifestyle, chronic diseases) and screening tools were administered by trained volunteers. These consist of the FRAIL scale, SARC-F to screen for sarcopenia, and mild cognitive impairment using the abbreviated screening for mild cognitive impairment (Abbreviated Memory Inventory for the Chinese). Blood pressure, body mass index, and grip strength were recorded. For phase 2, comprehensive geriatric assessment include questionnaires assessing lifestyle domain (physical activity, nutritional status using the Mini-Nutritional AssessmentShort Form), the physical domain (number of diseases and number of drugs, activities of daily living and instrumental activities of daily living disabilities, geriatric syndromes, self-rated health, sleep quality), cognitive and psychological domain (Mini-Mental State Examination, Geriatric Depression Scale), and social domain (income, housing, living satisfaction, family support). Results: The prevalence of pre-frailty and frailty were 52.4% and 12.5%, respectively. The prevalence for frailty increasing with age from 5.1% for those aged 65e69 years to 16.8% for those 75, being greater in women compared with men (13.9% vs 4.2%). Of those who were pre-frail or frail (n ¼ 529), 42.5% had sarcopenia and 60.7% had mild cognitive impairment. Among those who were frail (n ¼ 102), sarcopenia and mild cognitive impairment were also frequently present: 12.8% had sarcopenia, 14.7% had mild cognitive impairment, 63.7% had both sarcopenia and mild cognitive impairment, and only 8.8% had neither. In phase 2, participants who were classified as pre-frail or frail (n ¼ 529) were invited for further interviews; 255 participants (48.2%) returned. Compared with the pre-frail group, those in the frail group were less physically active, had higher number of chronic diseases, were taking more medications (more were taking sleeping pills), reported more falls, rated their health as poor, had higher prevalence of depressive symptoms and mild cognitive impairment, had higher prevalence of sarcopenia, and a high number of activities of daily living and instrumental activities of daily living disabilities. Conclusion: The FRAIL scale may be used as the first step in a step care approach to detecting frailty in the community, allowing targeted intervention to potentially retard decline and future disability. Ó 2015 AMDA e The Society for Post-Acute and Long-Term Care Medicine.
Frailty was developed over a decade ago as a concept describing the aging process as a biological/physiological state,1,2 one concept being a multiple deficit model1 whereas the other a description of a phenotype that excludes disability measures.2 Many epidemiological * Address correspondence to Jean Woo, Department of Medicine and Therapeutics, Prince of Wales Hospital, Shatin, N.T. Hong Kong. E-mail address: [email protected] (J. Woo). http://dx.doi.org/10.1016/j.jamda.2015.01.087 1525-8610/Ó 2015 AMDA e The Society for Post-Acute and Long-Term Care Medicine.
studies using either model have established the importance of the concept, as predicting many adverse health outcomes, quality of life, use of hospital services, and mortality, independent of diseases and disability. Recent literature have suggested that frailty may be divided into physical frailty represented by sarcopenia, and cognitive frailty represented by some degree of cognitive impairment (either the diagnosis of dementia or mild cognitive impairment).3e6 The close link with nutrition has also been described.7,8
2
J. Woo et al. / JAMDA xxx (2015) 1e8
In recent years research efforts have been directed towards the development of frailty screening tools suitable for use in the primary care setting, with a view to early identification followed by intervention to retard decline, particularly from the pre-frail to the frail category.9 Evidence shows that older people may move between different frailty states with time.10 Various consensus groups have emphasized the importance of incorporating frailty into practice,11,12 as well as national societies, nongovernment organizations, and think tanks.13 Various tools with varying items have been used in the primary care setting.2,14e17 A recent systematic review of the diagnostic test accuracy of simple instruments for identifying frailty in community-dwelling people concluded that no single test may be used because many have high sensitivity but low specificity.18 Among simple tools that have been used in the primary care setting, the FRAIL scale is short, consisting of 5 items (fatigue, resistance, ambulation, illnesses, and loss of weight) only, does not require measurements nor administration by healthcare professionals. Validity has been examined by comparing with the phenotypic and multiple deficit classifications.19 Recently, it has been used in a frailty survey in Ireland.20 Although many studies have been concerned with psychometric properties and validation with multidomain clinical assessments, few have explored its potential in the services setting or from a public health perspective. This study explores the feasibility of using the FRAIL scale in a community screening of older Chinese people aged 65 years and older, followed by clinical validation using comprehensive geriatric assessment of those classified as pre-frail or frail. Methods Study Population and Design Participants were mainly recruited from 3 districts in the New Territories East: Sha Tin, Tai Po, and North. The 3 districts had similar sociio-demographics with the rest of Hong Kong.21 An invitation letter was sent to elderly community centers, holiday centers for the elderly, neighborhood elderly centers, social centers for the elderly, offices of district councilor, owners’ corporations, and religious/ nonreligious organizations/societies in the 3 districts (95 units); 18 accepted. Community-dwelling older adults aged 65 years and older were invited to their affiliated centers for interview and assessment. Approval by the ethics committee of the Chinese University of Hong Kong was obtained. Written informed consent was obtained from all participants prior to the study. The study has a 2-phase design; phase 1 pertained to frailty screening assessment. Those who were classified as pre-frail or frail were invited for further comprehensive geriatric assessment at phase 2. For both phases of assessments, participants from whom information could not be directly obtained because of poor cognitive function or illness, their relatives and carers were interviewed instead. Phase 1: Frailty Screening The 5-item FRAIL scale was used for screening for frailty.22 There are 5 components: fatigue, resistance, ambulation, illnesses, and loss of weight. Frailty scores range from 0 to 5 (ie, 1 point for each component; 0 ¼ best to 5 ¼ worst) and represent frail (3e5), pre-frail (1e2), and robust (0) health status. Frailty screening assessment also included screening for sarcopenia using the SARC-F questionnaire23 and mild cognitive impairment using the Abbreviated Memory Inventory for the Chinese (AMIC).24 There are 5 components of SARC-F questionnaire: strength, assistance with walking, rise from a chair, climb stairs, and fall. The
SARC-F scores range from 0 to 10, with 0 to 2 points for each component. A score 4 is predictive of sarcopenia and poor outcomes. AMIC is an abbreviated version (5-item form) of the original 27-item Memory Inventory for the Chinese (validated for the diagnosis of mild cognitive impairment, with a sensitivity of 54.6%e65.3% and specificity of 57.4%).24 An AMIC score 3 is predictive of mild cognitive impairment. Demographics (age, sex, educational level, marital status) and lifestyle variables (smoking, alcohol intake) were obtained. Smoking status was divided into nonsmokers, ex-smokers, and current smokers. Alcohol intake was divided into 3 categories: nondrinkers, ex-drinkers, and current drinkers. Number of self-reported comorbidities was also assessed. Systolic and diastolic blood pressures were measured. Participants with systolic blood pressure
