Resources for the Comprehensive Geriatric Assessment based
Proactive and Personalised Primary Care of the Elderly
The frailty index is based on the concept that frailty is a consequence of interacting physical, psychological, and social factors. As deficits accumulate, people become increasingly vulnerable to adverse outcomes.
The 70 items of the original version Frailty Index (Rockwood K, 2005) are not to be considered as a fixed set of variables.
It has been reported that estimates of risk are strong when a minimum of 50 items are considered, but shorter versions (as low as 20 items) have also been explored (Rockwood K, 2012).
The frailty index is calculated as the number of deficits the patient has, divided by the number of deficits considered.
For example, in a frailty index based on a comprehensive geriatric assessment, an individual with impairments in 4 of 10 domains and with 10 of 24 possible co-morbidities would have 14 of 34 possible deficits, for a frailty index of 0.41 (Rockwood K, 1994)
The 70 items of the original version Frailty Index are too cumbersome to administer in the GP setting.
The Edmonton Frail Scale, was developed to be practical and usable in the community setting or at the bedside.
It is based on the following domains: cognition, general health status, functional independence, social support, medication use, nutrition, mood, continence, and functional performance.
In a community-based sample, the Edmonton Frail Scale, even when administered by non-specialists with no formal training in geriatric care, compared favorably with the clinical assessment of geriatric specialists who completed a more comprehensive evaluation (Rolfson DB, 2006)
Edmonton Frail Scale Template
Assessment of severity of frailty
A criticism of the frailty index is that it includes functional dependence as a deficit.
The criticism stems from the view that frailty should be seen as occurring prior to disability. According to this view, including dependence in instrumental and basic activities of daily living as a deficit confuses disability with frailty.
Proponents of the frailty index counter that frailty is not “all or none” and needs to be graded.
The frailty index can distinguish between people with and without disability by means of the number of deficits that they have, which is most important.
For example, a person disabled by a paraplegic injury would have a lower frailty index score and therefore would be considered less frail than a person with advanced cancer affecting multiple body systems (Koller K, 2013).
This is assuming the person who has suffered the injury resulting in paraplegia doesn’t have a concomitant condition such as renal failure or heart disease. In the absence of other health insults, such patients are less at risk of further morbidity or death than the patient with advanced cancer until they get another health insult or insults added to their frailty.
CORRELATION TO RISK OF DEATH
The frailty index is strongly correlated with the risk of death, with a correlation coefficient greater than 0.95.
As such, an individual’s frailty index score is considered an estimate of biologic age, which has greater correlation with associated morbidity and death than does chronological age (Kulminski AM, 2008).
In the general population, more than 99% of people have a frailty index value of less than 0.7.
As people approach this value, the chance of survival is greatly diminished; indeed, one report suggested that of those who have a frailty index value of more than 0.5 (based on a comprehensive geriatric assessment), 100% are dead by about 20 months later (Rockwood K, 2010).
In short, there is a limit to which deficits can be added before the system fails. In this sense, the frailty index is akin to the concept of physiologic reserve. Reserve is finite, and as a system loses redundancy it can no longer survive new stresses.
Understanding prognosis in the face of not just disease but also frailty can also help us focus not on disease but on health consequences of illness. Can the person think? Walk? Care for herself or himself? Interact with others? These questions need to be considered when end-of-life decisions are being discussed (Kulminski AM, 2006).
This page is an extension of Frailty
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