Letters to the Editor / JAMDA 15 (2014) 140e149
grounds of it having specific biological underpinnings and suggest that it also has better discriminate validity. There are defenses to be made for each argument (frailty as a specific phenotype vs frailty as deficit accumulation), but that is to what they amount. The issue is resolved, one way or the other, as soon as the premises of the argument are established. Even so, and despite considerable progress, the specific biological premises of the frailty phenotype are as yet elusive and occur only at a broad level of description. The approach taken with the frailty index (FI) makes no claim as to which processes give rise to deficits; in any case, these are likely to be several.3 The FI employs an approach that does not sacrifice individually informative pieces of data, as do “informative on average” approaches, such as searching for latent constructs, to use one of the examples suggested. For this reason, I am comfortable counting a whole range of problems, knowing that some will be more common than others, but that uncommon problems remain important to the people who experience them. That the FI itself has characteristic behaviors4,5 that allow highly generalizable description6 is an important explanatory variable across a range of important problems,7,8 and also informs clinical management4 (eg, in recognizing the increase in risk associated with increasing degrees of frailty) are reasons enough to continue with it. Interestingly, Xue and Varadhan concede the greater predictive validity of the frailty index, compared with the frailty phenotype, but then discount it. Even though the original intent of the frailty construct was to find a means of identifying people who, compared with others of the same age, were at greater risk of adverse health outcomes, and even though death is indubitably one such outcome, I do not entirely disagree with the notion of not becoming too focused on mortality prediction. That is both because there are many ways to die that would not be explained by frailty, and because for many people, there are outcomes worse than dying (catastrophic disability might be an example). In short, despite its convenience as a relevant, nonarbitrary and dichotomous outcome, there is more to predicting adverse events than predicting death. A more substantial objection to the frailty phenotype might be its lesser feasibility, resulting in loss of data on frailer people,9,10 or the burden of having to insist on problems with heavy housework being an indicator of “reduced activities” and not as an aspect of disability in instrumental activities of daily living.11 Likewise, for my part, the argument (cast as an aspect of discriminant validity) that 2 people with the same FI would need different clinical management based on which deficits they have acquired is obvious, without a claim to the contrary as far as I am aware, and equally true of the broad range of people described as frail by the phenotype. So why talk about frailty at all? Because frail older adults are at risk, the risk is generally under-appreciated by conventional approaches to risk stratification, and the overall approach required (to manage the complex needs of people as individuals) is often at odds with narrowly specialized approaches, “most responsible diagnoses” and discrete fee codes based on people having one thing wrong at a time.12 In this, I expect that Xue and Varadhan and all the signatories to the Journal of the American Medical Directors Association article agree. The frailty phenotype13 has usefully added much to our understanding and has greatly advanced how the word has entered the lexicon of contemporary medical practice.14 By coincidence, it came about at the same time as the deficit accumulation approach15 (each of which had prior underpinnings). Time will tell how this resolves, but that the 5 items counted in the frailty phenotype are a special case of deficit accumulation in my view remains a reasonable proposition,16e19 and one that is motivating additional inquires by our group.
145
References 1. Morley JE, Vellas B, Abellan van Kan G, et al. Frailty consensus: A call to action. J Am Med Dir Assoc 2013;14:392e397. 2. Xue QL, Varadhan R. What is missing in the validation of frailty instruments? J Am Med Dir Assoc 2014;15:141e142. 3. López-Otín C, Blasco MA, Partridge L, et al. The hallmarks of aging. Cell 2013; 153:1194e1217. 4. Rockwood K, Mitnitski A. Frailty defined by deficit accumulation and geriatric medicine defined by frailty. Clin Geriatr Med 2011;27:17e26. 5. Bennett S, Song X, Mitnitski A, Rockwood K. A limit to frailty in very old, community-dwelling people: A secondary analysis of the Chinese longitudinal health and longevity study. Age Ageing 2013;42:372e377. 6. Mitnitski A, Song X, Rockwood K. Assessing biological aging: The origin of deficit accumulation. Biogerontology 2013;14:709e717. 7. Parks RJ, Fares E, Macdonald JK, et al. A procedure for creating a frailty index based on deficit accumulation in aging mice. J Gerontol A Biol Sci Med Sci 2012; 67:217e227. 8. Theou O, Brothers TD, Rockwood MR, et al. Exploring the relationship between national economic indicators and relative fitness and frailty in middle-aged and older Europeans. Age Ageing 2013;42:614e619. 9. Ravindrarajah R, Lee DM, Pye SR, 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;57:360e368. 10. Collerton J, Martin-Ruiz C, Davies K, et al. Frailty and the role of inflammation, immunosenescence and cellular ageing in the very old: Cross-sectional findings from the Newcastle 85þ Study. Mech Ageing Dev 2012;133:456e466. 11. Eckel SP, Bandeen-Roche K, Chaves PH, et al. Surrogate screening models for the low physical activity criterion of frailty. Aging Clin Exp Res 2011;23:209e216. 12. Clegg A, Young J, Iliffe S, et al. Frailty in elderly people. Lancet 2013;381: 752e762. 13. Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: Evidence for a phenotype. J Gerontol A Biol Sci Med Sci 2001;56:M146eM156. 14. Bouillon K, Kivimaki M, Hamer M, et al. Measures of frailty in population-based studies: An overview. BMC Geriatr 2013;13:64. 15. Mitnitski AB, Mogilner AJ, Rockwood K. Accumulation of deficits as a proxy measure of aging. Scientific World J 2001;1:323e336. 16. Davis DH, Rockwood MR, Mitnitski AB, Rockwood K. Impairments in mobility and balance in relation to frailty. Arch Gerontol Geriatr 2011;53:79e83. 17. Mitnitski A, Fallah N, Rockwood MR, Rockwood K. Transitions in cognitive status in relation to frailty in older adults: A comparison of three frailty measures. J Nutr Health Aging 2011;15:863e867. 18. Rolfson DB, Wilcock G, Mitnitski A, et al. An assessment of neurocognitive speed in relation to frailty. Age Ageing 2013;42:191e196. 19. Theou O, Brothers TD, 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;61:1537e1551.
Kenneth Rockwood, MD, FRCPC, FRCP, FCAHS Division of Geriatric Medicine Dalhousie University Halifax, Nova Scotia, Canada http://dx.doi.org/10.1016/j.jamda.2013.11.013
Response to the Letter to the Editor: “Frailty Consensus: A Call to Action” To the Editor: Regarding the first point that Drs Xue and Varadhan1 made in their letter, I agree with the view that the frailty index (FI) is the result of the accumulation of deficits leading to the frailty construct. I do not think, however, that the frailty phenotype (FP) is “causing rather than being caused by the phenotypic components” as is stated in the letter. The phenotypic components, strongly related to sarcopenia, actually cause the frailty construct. In this regard, the FP is not so different from the FI model, although it is limited to physical frailty, where the FI model is more encompassing.2
146
Letters to the Editor / JAMDA 15 (2014) 140e149
Fig. 1. Screening and prevention strategy for sarcopenia.
Addressing Xue and Varadhan’s1 comments on screening, screening is not the same as diagnosing. A screening tool needs to have a high sensitivity and high negative predictive value, and specificity comes in the second place; therefore, you always will have false positives. Screening for frailty will indeed give a different outcome when using different tools. Screening, however, will be the first step in a specific management strategy. The Gérontopôle Frailty Screening Tool, for example, aims to identify people who might be frail (screening step) and who are candidates for a more extensive evaluation (diagnosing step).3 The next step will be the prevention or correction of the functional disabilities. Frailty becomes more prevalent with increasing age, but it is a dynamic condition starting at much younger age. Therefore, screening in persons older than 70 seems to be logical, although younger people might be at risk. Given the intrinsic, age-related character, primary prevention, if possible, should start as early as the onset of the underlying processes. Xue and Varadhan make a point when they state that weight loss4 is not ideal to launch screening and that earlier manifestations such as slowness and weakness should be targeted. These are, in fact, components of sarcopenia, and are highly related to frailty. Indeed, the actual proposed screening tools are focused at identifying subjects corresponding to the diagnostic criteria for sarcopenia and frailty. According to the European Working Group on Sarcopenia in Older People5 and the International Working Group on Sarcopenia6 gait speed is recommended as a cut-off point to refer subjects for further assessment. But then again, to identify subjects susceptible for primary and secondary prevention, the phase corresponding to decreased gait speed is probably too advanced and suggests already an indication for tertiary prevention
and/or treatment. Therefore, muscle performance assessment, using an easy and reliable method, and providing a score on a continuous scale, is probably more suitable to identify persons with muscle weakness without presenting clinical signs of functional disability. In the strategy of dealing with frailty, prevention should be distinguished from treatment. However, interventions will target similar underlying pathophysiological processes. The difference lies in the actual support and coaching of the individual. Therefore, an algorithm for management of the frailty process should be developed to guide the actual interventions needed in different stages comparable with the algorithm proposed for sarcopenia (Figure 1).7 References 1. Xue QL, Varadhan R. What is missing in the validation of frailty instruments? J Am Med Dir Assoc 2014;15:141e142. 2. Fried LP, Tangen CM, Walston J, et al. Frialty in older adults: Evidence for a phenotype. J Geront A Biol Sci Med Sci 2001;56:M146eM156. 3. Rougé Bugat M-E, Cestac P, Oustric S, et al. Detecting frailty in primary care: A major challenge for primary care physicians. J Am Med Dir Assoc 2012;13: 669e672. 4. Soenen S, Chapman IM. Body weight, anorexia, and undernutrition in older people. J Am Med Dir Assoc 2013;14:642e648. 5. Cruz-Jentoft AJ, Baeyens JP, Bauer JM, et al. Sarcopenia: European consensus on definition and diagnosis: Report of the European Working Group on Sarcopenia in Older People. Age Ageing 2010;39:412e423. 6. Fielding RA, Vellas B, Evans WJ, et al. Sarcopenia: An undiagnosed condition in older adults. Current consensus definition: Prevalence, etiology, and consequences. International working group on sarcopenia. J Am Med Dir Assoc 2011; 12:249e256. 7. Vandewoude M, Bautmans I. Sarcopenia: Is It Preventable? In: Cruz-Jentoft A, Morley J, eds. Sarcopenia. Chichester, UK: Wiley-Blackwell Publishing, 2012, p. 324e337.
Letters to the Editor / JAMDA 15 (2014) 140e149
Maurits Vandewoude, MD, PhD Department of Geriatrics ZNA St. Elizabeth Hospital University of Antwerp Antwerp, Belgium
147
an integrated signal of overall increased catabolic activation and anabolic blunting. The complexity of the mechanisms of tissue wasting resulting in weight loss does not prevent a strong predictive power of this simple assessment. References
http://dx.doi.org/10.1016/j.jamda.2013.11.015
Response to the Letter to the Editor From Xue and Varadhan Titled “What Is Missing in the Validation of Frailty Instruments?” To the Editor: Drs Xue and Vardhan comment in their letter on the validity and applicability of assessment tools to address frailty as a relevant clinical complication of ageing and of progressing disabling disease.1 They dwell on the distinction between 2 principal approaches to defining physical frailty based on opposite directions of causality of the indicators and the clinically construct of frailty. While this distinction may emphasize the pathophysiologically relevant specific characteristics of both concepts, it remains a theoretical disputation of secondary relevance when it comes to clinical applicability of the assessment tools to identify a patient with frailty and at risk of disability. Clearly, there is an unmet clinical need to identify patients with frailty in a range of chronic diseases,2 to prevent or reverse further functional decline, and to improve the symptomatic state and, potentially, even the prognosis. As the title of the consensus statement by Morley et al. insinuates, clinical action is warranted to meet the challenge of growing numbers of patients with or at risk of frailty.3 To that aim, a practical approach is required and a recommendation is needed on how, in whom, and when screening activities should begin to identify frailty in the clinical context of elderly and often multimorbid patients. Notably, a previous effort to find a consensus on frailty agreed merely on the need to define frailty as a condition to be clinically addressed.4 It failed, however, to provide such a practical framework as the wider variety of theoretical considerations that were to be included by the consensus group prevented a joint concept. The consensus article by Morley et al mastered this hurdle and managed to combine the expertise from delegates from 6 major international, European, and US societies and independent experts in a joint statement to define the clinical problem, to recommend a clinically applicable approach to screening, and to identify a target population most likely to benefit from such a concept. The consensus reached may, therefore, be an acceptable clinical compromise on a number of pathophysiologic and theoretical specifics as pinpointed by Xue and Vardhan that nevertheless allows for clinical meaningful and highly warranted measures. The direction of the causal interaction of the indicators of frailty may not be the determinant of the validity and/or accuracy of this marker. In fact, causality is not at all the foremost characteristic to describe the quality of a predictive marker. Weight loss in the context of a chronic disease is a strong and independent clinical indicator of progressing disease and a marker of impaired prognosis. It is neither an isolated cause of higher mortality nor a unidirectional sequel of the disease but rather
1. Xue QL, Varadhan R. What is missing in the validation of frailty instruments? J Am Med Dir Assoc 2014;15:141e142. 2. von Haehling S, Anker SD, Doehner W, et al. Frailty and heart disease. Int J Cardiol 2013;168:1745e1747. 3. Morley JE, Vellas B, van Kan GA, et al. Frailty consensus: A call to action. J Am Med Dir Assoc 2013;14:392e397. 4. Rockwood K. What would make a definition of frailty successful? Age Ageing 2005;34:432e434.
Wolfram Doehner, MD, PhD Nadja Scherbakov, MD Center for Stroke Research BerlineCSB Charité-Universitätsmedizin Berlin, Germany http://dx.doi.org/10.1016/j.jamda.2013.11.014
Response to the Letter to the Editor Entitled “What Is Missing in the Validation of Frailty Instruments?” by Drs Xue and Varadhan: The Toulouse Frailty Clinic, 1 Year of Clinical Experience To the Editor: We thank Drs Xue and Varadhan for their comments1 about the consensus paper recently published in the Journal.2 We would like to start by stressing that one of the main aims of the consensus paper was to generate enthusiasm on the topic and increase awareness in the scientific community about the importance of screening and assessing frailty in older adults. To this aim, a group of experts met in Orlando proposing “A call to action.” The reactions of the scientific community, such as the letter of Drs Xue and Varadhan, shows that frailty assessment is a hot topic and that the consensus paper fulfils its expectancies. We would like to provide some of the clinical data obtained from the existing Toulouse Frailty Platform3 during the year 2012. Before continuing we need to stress the limitations of our results as we are acting in the clinical practice, the Gérontopôle Frailty Screening Tool (GFST) still presents limitations, mainly the lack of methodological validation, and the Toulouse Frailty Platform is not yet standardized or supported by what authors are asking. The GFST,4 used in France to screen for frailty, was expanded to be used by general practitioners (GP). The proposed scale should be easy to use, not time consuming, and be straightforward in identifying frail older adults in need of a standardized frailty assessment at the Toulouse Frailty Platform. As promoted by Dr Clegg, the distinction of frail elderly people from those who are not frail should be an essential part in any health-care encounter,5 although low time consumption of the assessment is crucial to ascertain feasibility.
grounds of it having specific biological underpinnings and suggest that it also has better discriminate validity. There are defenses to be made for each argument (frailty as a specific phenotype vs frailty as deficit accumulation), but that is to what they amount. The issue is resolved, one way or the other, as soon as the premises of the argument are established. Even so, and despite considerable progress, the specific biological premises of the frailty phenotype are as yet elusive and occur only at a broad level of description. The approach taken with the frailty index (FI) makes no claim as to which processes give rise to deficits; in any case, these are likely to be several.3 The FI employs an approach that does not sacrifice individually informative pieces of data, as do “informative on average” approaches, such as searching for latent constructs, to use one of the examples suggested. For this reason, I am comfortable counting a whole range of problems, knowing that some will be more common than others, but that uncommon problems remain important to the people who experience them. That the FI itself has characteristic behaviors4,5 that allow highly generalizable description6 is an important explanatory variable across a range of important problems,7,8 and also informs clinical management4 (eg, in recognizing the increase in risk associated with increasing degrees of frailty) are reasons enough to continue with it. Interestingly, Xue and Varadhan concede the greater predictive validity of the frailty index, compared with the frailty phenotype, but then discount it. Even though the original intent of the frailty construct was to find a means of identifying people who, compared with others of the same age, were at greater risk of adverse health outcomes, and even though death is indubitably one such outcome, I do not entirely disagree with the notion of not becoming too focused on mortality prediction. That is both because there are many ways to die that would not be explained by frailty, and because for many people, there are outcomes worse than dying (catastrophic disability might be an example). In short, despite its convenience as a relevant, nonarbitrary and dichotomous outcome, there is more to predicting adverse events than predicting death. A more substantial objection to the frailty phenotype might be its lesser feasibility, resulting in loss of data on frailer people,9,10 or the burden of having to insist on problems with heavy housework being an indicator of “reduced activities” and not as an aspect of disability in instrumental activities of daily living.11 Likewise, for my part, the argument (cast as an aspect of discriminant validity) that 2 people with the same FI would need different clinical management based on which deficits they have acquired is obvious, without a claim to the contrary as far as I am aware, and equally true of the broad range of people described as frail by the phenotype. So why talk about frailty at all? Because frail older adults are at risk, the risk is generally under-appreciated by conventional approaches to risk stratification, and the overall approach required (to manage the complex needs of people as individuals) is often at odds with narrowly specialized approaches, “most responsible diagnoses” and discrete fee codes based on people having one thing wrong at a time.12 In this, I expect that Xue and Varadhan and all the signatories to the Journal of the American Medical Directors Association article agree. The frailty phenotype13 has usefully added much to our understanding and has greatly advanced how the word has entered the lexicon of contemporary medical practice.14 By coincidence, it came about at the same time as the deficit accumulation approach15 (each of which had prior underpinnings). Time will tell how this resolves, but that the 5 items counted in the frailty phenotype are a special case of deficit accumulation in my view remains a reasonable proposition,16e19 and one that is motivating additional inquires by our group.
145
References 1. Morley JE, Vellas B, Abellan van Kan G, et al. Frailty consensus: A call to action. J Am Med Dir Assoc 2013;14:392e397. 2. Xue QL, Varadhan R. What is missing in the validation of frailty instruments? J Am Med Dir Assoc 2014;15:141e142. 3. López-Otín C, Blasco MA, Partridge L, et al. The hallmarks of aging. Cell 2013; 153:1194e1217. 4. Rockwood K, Mitnitski A. Frailty defined by deficit accumulation and geriatric medicine defined by frailty. Clin Geriatr Med 2011;27:17e26. 5. Bennett S, Song X, Mitnitski A, Rockwood K. A limit to frailty in very old, community-dwelling people: A secondary analysis of the Chinese longitudinal health and longevity study. Age Ageing 2013;42:372e377. 6. Mitnitski A, Song X, Rockwood K. Assessing biological aging: The origin of deficit accumulation. Biogerontology 2013;14:709e717. 7. Parks RJ, Fares E, Macdonald JK, et al. A procedure for creating a frailty index based on deficit accumulation in aging mice. J Gerontol A Biol Sci Med Sci 2012; 67:217e227. 8. Theou O, Brothers TD, Rockwood MR, et al. Exploring the relationship between national economic indicators and relative fitness and frailty in middle-aged and older Europeans. Age Ageing 2013;42:614e619. 9. Ravindrarajah R, Lee DM, Pye SR, 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;57:360e368. 10. Collerton J, Martin-Ruiz C, Davies K, et al. Frailty and the role of inflammation, immunosenescence and cellular ageing in the very old: Cross-sectional findings from the Newcastle 85þ Study. Mech Ageing Dev 2012;133:456e466. 11. Eckel SP, Bandeen-Roche K, Chaves PH, et al. Surrogate screening models for the low physical activity criterion of frailty. Aging Clin Exp Res 2011;23:209e216. 12. Clegg A, Young J, Iliffe S, et al. Frailty in elderly people. Lancet 2013;381: 752e762. 13. Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: Evidence for a phenotype. J Gerontol A Biol Sci Med Sci 2001;56:M146eM156. 14. Bouillon K, Kivimaki M, Hamer M, et al. Measures of frailty in population-based studies: An overview. BMC Geriatr 2013;13:64. 15. Mitnitski AB, Mogilner AJ, Rockwood K. Accumulation of deficits as a proxy measure of aging. Scientific World J 2001;1:323e336. 16. Davis DH, Rockwood MR, Mitnitski AB, Rockwood K. Impairments in mobility and balance in relation to frailty. Arch Gerontol Geriatr 2011;53:79e83. 17. Mitnitski A, Fallah N, Rockwood MR, Rockwood K. Transitions in cognitive status in relation to frailty in older adults: A comparison of three frailty measures. J Nutr Health Aging 2011;15:863e867. 18. Rolfson DB, Wilcock G, Mitnitski A, et al. An assessment of neurocognitive speed in relation to frailty. Age Ageing 2013;42:191e196. 19. Theou O, Brothers TD, 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;61:1537e1551.
Kenneth Rockwood, MD, FRCPC, FRCP, FCAHS Division of Geriatric Medicine Dalhousie University Halifax, Nova Scotia, Canada http://dx.doi.org/10.1016/j.jamda.2013.11.013
Response to the Letter to the Editor: “Frailty Consensus: A Call to Action” To the Editor: Regarding the first point that Drs Xue and Varadhan1 made in their letter, I agree with the view that the frailty index (FI) is the result of the accumulation of deficits leading to the frailty construct. I do not think, however, that the frailty phenotype (FP) is “causing rather than being caused by the phenotypic components” as is stated in the letter. The phenotypic components, strongly related to sarcopenia, actually cause the frailty construct. In this regard, the FP is not so different from the FI model, although it is limited to physical frailty, where the FI model is more encompassing.2
146
Letters to the Editor / JAMDA 15 (2014) 140e149
Fig. 1. Screening and prevention strategy for sarcopenia.
Addressing Xue and Varadhan’s1 comments on screening, screening is not the same as diagnosing. A screening tool needs to have a high sensitivity and high negative predictive value, and specificity comes in the second place; therefore, you always will have false positives. Screening for frailty will indeed give a different outcome when using different tools. Screening, however, will be the first step in a specific management strategy. The Gérontopôle Frailty Screening Tool, for example, aims to identify people who might be frail (screening step) and who are candidates for a more extensive evaluation (diagnosing step).3 The next step will be the prevention or correction of the functional disabilities. Frailty becomes more prevalent with increasing age, but it is a dynamic condition starting at much younger age. Therefore, screening in persons older than 70 seems to be logical, although younger people might be at risk. Given the intrinsic, age-related character, primary prevention, if possible, should start as early as the onset of the underlying processes. Xue and Varadhan make a point when they state that weight loss4 is not ideal to launch screening and that earlier manifestations such as slowness and weakness should be targeted. These are, in fact, components of sarcopenia, and are highly related to frailty. Indeed, the actual proposed screening tools are focused at identifying subjects corresponding to the diagnostic criteria for sarcopenia and frailty. According to the European Working Group on Sarcopenia in Older People5 and the International Working Group on Sarcopenia6 gait speed is recommended as a cut-off point to refer subjects for further assessment. But then again, to identify subjects susceptible for primary and secondary prevention, the phase corresponding to decreased gait speed is probably too advanced and suggests already an indication for tertiary prevention
and/or treatment. Therefore, muscle performance assessment, using an easy and reliable method, and providing a score on a continuous scale, is probably more suitable to identify persons with muscle weakness without presenting clinical signs of functional disability. In the strategy of dealing with frailty, prevention should be distinguished from treatment. However, interventions will target similar underlying pathophysiological processes. The difference lies in the actual support and coaching of the individual. Therefore, an algorithm for management of the frailty process should be developed to guide the actual interventions needed in different stages comparable with the algorithm proposed for sarcopenia (Figure 1).7 References 1. Xue QL, Varadhan R. What is missing in the validation of frailty instruments? J Am Med Dir Assoc 2014;15:141e142. 2. Fried LP, Tangen CM, Walston J, et al. Frialty in older adults: Evidence for a phenotype. J Geront A Biol Sci Med Sci 2001;56:M146eM156. 3. Rougé Bugat M-E, Cestac P, Oustric S, et al. Detecting frailty in primary care: A major challenge for primary care physicians. J Am Med Dir Assoc 2012;13: 669e672. 4. Soenen S, Chapman IM. Body weight, anorexia, and undernutrition in older people. J Am Med Dir Assoc 2013;14:642e648. 5. Cruz-Jentoft AJ, Baeyens JP, Bauer JM, et al. Sarcopenia: European consensus on definition and diagnosis: Report of the European Working Group on Sarcopenia in Older People. Age Ageing 2010;39:412e423. 6. Fielding RA, Vellas B, Evans WJ, et al. Sarcopenia: An undiagnosed condition in older adults. Current consensus definition: Prevalence, etiology, and consequences. International working group on sarcopenia. J Am Med Dir Assoc 2011; 12:249e256. 7. Vandewoude M, Bautmans I. Sarcopenia: Is It Preventable? In: Cruz-Jentoft A, Morley J, eds. Sarcopenia. Chichester, UK: Wiley-Blackwell Publishing, 2012, p. 324e337.
Letters to the Editor / JAMDA 15 (2014) 140e149
Maurits Vandewoude, MD, PhD Department of Geriatrics ZNA St. Elizabeth Hospital University of Antwerp Antwerp, Belgium
147
an integrated signal of overall increased catabolic activation and anabolic blunting. The complexity of the mechanisms of tissue wasting resulting in weight loss does not prevent a strong predictive power of this simple assessment. References
http://dx.doi.org/10.1016/j.jamda.2013.11.015
Response to the Letter to the Editor From Xue and Varadhan Titled “What Is Missing in the Validation of Frailty Instruments?” To the Editor: Drs Xue and Vardhan comment in their letter on the validity and applicability of assessment tools to address frailty as a relevant clinical complication of ageing and of progressing disabling disease.1 They dwell on the distinction between 2 principal approaches to defining physical frailty based on opposite directions of causality of the indicators and the clinically construct of frailty. While this distinction may emphasize the pathophysiologically relevant specific characteristics of both concepts, it remains a theoretical disputation of secondary relevance when it comes to clinical applicability of the assessment tools to identify a patient with frailty and at risk of disability. Clearly, there is an unmet clinical need to identify patients with frailty in a range of chronic diseases,2 to prevent or reverse further functional decline, and to improve the symptomatic state and, potentially, even the prognosis. As the title of the consensus statement by Morley et al. insinuates, clinical action is warranted to meet the challenge of growing numbers of patients with or at risk of frailty.3 To that aim, a practical approach is required and a recommendation is needed on how, in whom, and when screening activities should begin to identify frailty in the clinical context of elderly and often multimorbid patients. Notably, a previous effort to find a consensus on frailty agreed merely on the need to define frailty as a condition to be clinically addressed.4 It failed, however, to provide such a practical framework as the wider variety of theoretical considerations that were to be included by the consensus group prevented a joint concept. The consensus article by Morley et al mastered this hurdle and managed to combine the expertise from delegates from 6 major international, European, and US societies and independent experts in a joint statement to define the clinical problem, to recommend a clinically applicable approach to screening, and to identify a target population most likely to benefit from such a concept. The consensus reached may, therefore, be an acceptable clinical compromise on a number of pathophysiologic and theoretical specifics as pinpointed by Xue and Vardhan that nevertheless allows for clinical meaningful and highly warranted measures. The direction of the causal interaction of the indicators of frailty may not be the determinant of the validity and/or accuracy of this marker. In fact, causality is not at all the foremost characteristic to describe the quality of a predictive marker. Weight loss in the context of a chronic disease is a strong and independent clinical indicator of progressing disease and a marker of impaired prognosis. It is neither an isolated cause of higher mortality nor a unidirectional sequel of the disease but rather
1. Xue QL, Varadhan R. What is missing in the validation of frailty instruments? J Am Med Dir Assoc 2014;15:141e142. 2. von Haehling S, Anker SD, Doehner W, et al. Frailty and heart disease. Int J Cardiol 2013;168:1745e1747. 3. Morley JE, Vellas B, van Kan GA, et al. Frailty consensus: A call to action. J Am Med Dir Assoc 2013;14:392e397. 4. Rockwood K. What would make a definition of frailty successful? Age Ageing 2005;34:432e434.
Wolfram Doehner, MD, PhD Nadja Scherbakov, MD Center for Stroke Research BerlineCSB Charité-Universitätsmedizin Berlin, Germany http://dx.doi.org/10.1016/j.jamda.2013.11.014
Response to the Letter to the Editor Entitled “What Is Missing in the Validation of Frailty Instruments?” by Drs Xue and Varadhan: The Toulouse Frailty Clinic, 1 Year of Clinical Experience To the Editor: We thank Drs Xue and Varadhan for their comments1 about the consensus paper recently published in the Journal.2 We would like to start by stressing that one of the main aims of the consensus paper was to generate enthusiasm on the topic and increase awareness in the scientific community about the importance of screening and assessing frailty in older adults. To this aim, a group of experts met in Orlando proposing “A call to action.” The reactions of the scientific community, such as the letter of Drs Xue and Varadhan, shows that frailty assessment is a hot topic and that the consensus paper fulfils its expectancies. We would like to provide some of the clinical data obtained from the existing Toulouse Frailty Platform3 during the year 2012. Before continuing we need to stress the limitations of our results as we are acting in the clinical practice, the Gérontopôle Frailty Screening Tool (GFST) still presents limitations, mainly the lack of methodological validation, and the Toulouse Frailty Platform is not yet standardized or supported by what authors are asking. The GFST,4 used in France to screen for frailty, was expanded to be used by general practitioners (GP). The proposed scale should be easy to use, not time consuming, and be straightforward in identifying frail older adults in need of a standardized frailty assessment at the Toulouse Frailty Platform. As promoted by Dr Clegg, the distinction of frail elderly people from those who are not frail should be an essential part in any health-care encounter,5 although low time consumption of the assessment is crucial to ascertain feasibility.
