[Factors contributing to frailty in institutionalized older adults: a multi-institutional cross-sectional study].

AIM: To reveal the characteristics and the oral function of institutionalized frail older adults and the factors contributing to frailty. METHODS: This multicenter, cross-sectional study included 214 patients. A questionnaire was administered to registered dietitians from these institutions. Sex, age, height, weight, grip strength, calf circumference, level of care need, FRAIL-NH, MNA® -SF, dysphagia, food form and water thickening, number of medications, major diseases, comorbidities, independence in daily living of older people with dementia, use of medication with dry mouth, nutritional care issues (malnutrition-related problems) by multiple occupations in Nutrition and Eating Swallowing Screening, Assessment and Monitoring, and nine oral-related items were evaluated. RESULTS: One hundred six patients (49.5%) were classified as frail, 75% of the patients were women, and the mean BMI was 19.7 kg/m2. Older adults with frailty were characterized by high care needs, malnutrition, multiple comorbidities, multiple medications, eating and swallowing disorders, the requirement of feeding assistance, and the need to adjust the shape of meals and fluids. The multivariable OR (95%CI) for "choking and residue problems" was 1.81 (1.20-2.73), while that for "dietary concentration problems" was 4.28 (2.10-8.74). CONCLUSION: Caregivers must maintain posture and provide meal assistance. Professionals in various occupations must adjust the proper food form and medication content. Meal times must be examined in consideration of the times at which drugs will be most effective. Oral care must be provided, and an environment must be created to help the subject concentrate. Focusing on problems of choking, residue, and concentration on meals is expected to improve frailty, aspiration pneumonia, and the prognosis of institutionalized older adults.

Accessing the discriminatory performance of FRAIL-NH in two-class and three-class frailty and examining its agreement with the frailty index among nursing home residents in mainland China.

BACKGROUND: FRAIL-NH has been commonly used to assess frailty in nursing home residents and validated in many ethnic populations; however, it has not been validated in mainland China, where such an assessment tool is lacking. This study aimed to (1) assess the discriminatory performance of FRAIL-NH in two-class frailty (non-frail+ pre-frail vs. frail) and three-class frailty (non-frail vs. pre-frail vs. frail), based on the Frailty Index (FI), (2) determine the appropriate cutoff points for FRAIL-NH that distinguish two-class and three-class frailty, and (3) examine the agreement in classification between FRAIL-NH and FI. METHODS: A cross-sectional study of 302 residents aged 60 years or older from six nursing homes in Changsha was conducted. The FRAIL-NH scale and 34-item FI were used to measure frailty. Two-way and three-way receiver operating characteristic (ROC) curves were used to estimate the performance of FRAIL-NH. Cohen's Kappa statistics were used to examine the agreement between these two measures. RESULTS: The agreement between FRAIL-NH and FI ranged from 0.33 to 0.55. Regardless of what FI cutoff points were based on, the volume under the ROC surface (VUS) for FRAIL-NH from the three-way ROC were higher than the VUS of a useless test (1/6), and the area under the ROC curve (AUC) for FRAIL-NH from the two-way ROC were higher than the clinically meaningless value (0.5). When using FI cutoff points of 0.20 for pre-frail and 0.45 for frail, FRAIL-NH cutoff points of 1 and 9 in classifying three-class frailty had the highest VUS and the largest correct classification rates. Whichever FI was chosen, the performance of FRAIL-NH in distinguishing between pre-frailty and frailty, and between non-frailty and pre-frailty was equivalent. According to FRAIL-NH, the proportion of individuals with frailty misclassified as pre-frailty was higher than that of individuals with non-frailty misclassified as pre-frailty. CONCLUSION: FRAIL-NH can be used as a preliminary frailty screening tool in nursing homes in mainland China. FI should be further used especially for those classified as pre-frailty by FRAIL-NH. It is not advisable to simply combine adjacent two classes of FRAIL-NH to create a new frailty variable in research settings.

Frailty in Nursing Homes-A Prospective Study Comparing the FRAIL-NH and the Clinical Frailty Scale.

OBJECTIVES: Frailty is common in nursing home (NH) residents, but its prevalence in German institutions is unknown. Valid and easy-to-use screening tools are needed to identify frail residents. We used the FRAIL-NH scale and the Clinical Frailty Scale (CFS) to (1) obtain the prevalence of frailty, (2) investigate the agreement between both instruments, and (3) evaluate their predictive validity for adverse health events in German NH residents. DESIGN: Prospective cohort study. SETTING AND PARTICIPANTS: German NH residents (n = 246, age 84 ± 8 years, 67% female). METHODS: Frailty status was categorized according to FRAIL-NH (nonfrail, frail, most frail) and CFS (not frail, mild to moderately frail, severely frail). Agreement between instruments was examined by Spearman correlation, an area under the receiver operating characteristic curve (AUC) with 95% CI, and sensitivity and specificity using the "most frail" category of FRAIL-NH as reference standard. Adverse health events (death, hospital admissions, falls) were recorded for 12 months, and multivariate cox and logistic regression models calculated. RESULTS: According to FRAIL-NH, 71.1% were most frail, 26.4% frail, and 2.5% nonfrail. According to CFS, 66.3% were severely frail, 26.8% mild to moderately frail, and 6.9% not frail. Both scales correlated significantly (r = 0.78; R2 = 60%). The AUC was 0.92 (95% CI 0.88-0.96). Using a CFS cutoff of 7 points, sensitivity was 0.90 and specificity 0.92. The frailest groups according to both instruments had an increased risk of death [FRAIL-NH hazard ratio (HR) 2.19, 95% CI 1.21-3.99; CFS HR 2.56, 95% CI 1.43-4.58] and hospital admission [FRAIL-NH odds ratio (OR) 1.95, 95% CI 1.06-3.58; CFS OR 1.79, 95% CI 1.01-3.20] compared to less frail residents. The FRAIL-NH predicted recurrent faller status (OR 2.57, 95% CI 1.23-5.39). CONCLUSIONS AND IMPLICATIONS: Frailty is highly prevalent in German NH residents. Both instruments show good agreement despite different approaches and are able to predict adverse health outcomes. Based on our findings and because of its simple administration, CFS may be an alternative to FRAIL-NH for assessing frailty in NHs.

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

OBJECTIVES: 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. DESIGN: 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. MEASUREMENTS: 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. RESULTS: 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.

The FRAIL-NH Scale: Systematic Review of the Use, Validity and Adaptations for Frailty Screening in Nursing Homes.

OBJECTIVES: To investigate frailty prevalence, cross-sectional associations, predictive validity, concurrent validity, and cross-cultural adaptations of the FRAIL-NH scale. DESIGN: Systematic review. SETTING AND PARTICIPANTS: Frail residents living in nursing homes. METHODS: MEDLINE, EMBASE, CINAHL, and Cochrane Library were searched from January 2015 to June 2021 for primary studies that used the FRAIL-NH scale, irrespective of study designs and publication language. RESULTS: Overall, 40 studies conducted across 20 countries utilized the FRAIL-NH scale; majority in Australia (n=14), followed by China (n=6), United States (n=3), and Spain (n=3). The scale has been translated and back-translated into Brazilian Portuguese, Chinese, and Japanese. Various cut-offs have been used, with ≥2 and ≥6 being the most common cut-offs for frail and most frail, respectively. When defined using these cut-offs, frailty prevalence varied from 15.1-79.5% (frail) to 28.5-75.0% (most frail). FRAIL-NH predicted falls (n=2), hospitalization or length of stay (n=4), functional or cognitive decline (n=4), and mortality (n=9) over a median follow-up of 12 months. FRAIL-NH has been compared to 16 other scales, and was correlated with Fried's phenotype (FP), Frailty Index (FI), and FI-Lab. Four studies reported fair-to-moderate agreements between FRAIL-NH and FI, FP, and the Comprehensive Geriatric Assessment. Ten studies assessed the sensitivity and specificity of different FRAIL-NH cut-offs, with ≥8 having the highest sensitivity (94.1%) and specificity (82.8%) for classifying residents as frail based on FI, while two studies reported an optimal cut-off of ≥2 based on FI and FP, respectively. CONCLUSION: In seven years, the FRAIL-NH scale has been applied in 20 countries and adapted into three languages. Despite being applied with a range of cut-offs, FRAIL-NH was associated with higher care needs and demonstrated good agreement with other well-established but more complex scales. FRAIL-NH was predictive of adverse outcomes across different settings, highlighting its value in guiding care for frail residents in nursing homes.

Prediction of Death with the FRAIL-NH in Institutionalized Older Adults: A Longitudinal Study from a Middle-Income Country.

BACKGROUND/OBJECTIVES: Frailty is common in nursing homes. However, few studies reported longitudinal validation for death prediction or cut-off scores with the FRAIL-NH, which is designed to be used in nursing homes. Moreover, no studies came from Latin America, where frailty is highly prevalent. Our objectives were to evaluate (1) the prevalence of frailty according to the FRAIL-NH scale, and (2) its association to and the best cut-off score for predicting death after 12 months. DESIGN: longitudinal study with 12-month follow-up. SETTING: 6 nursing homes in southwest of Brazil. PARTICIPANTS: 293 residents with 60 years old or more. METHODS: Frailty was evaluated through the FRAIL-NH scale. Logistic regression was used to estimate the associated between frailty and mortality adjusted for age and sex. ROC curve was used to evaluate the accuracy of the scale for mortality prediction. RESULTS: Frailty was prevalent (47.4%) and was associated with death (odds ratio=1.31, 95% confidence interval [CI]=1.18-1.48, p<0.001). The area under the curve was 0.741 (95%CI=0.68-0.79). The sensitivity and specificity of the FRAIL-NH scale according to the best value of the Youden Index was 72.9% and 66.5%, respectively, for a cut-off > 8 points. CONCLUSIONS: Frailty is prevalent in nursing homes according to the FRAIL-NH and it was associated with one-year prediction of death for a cut-off > 8 points.

The Prevalence of Frailty by the FRAIL-NH Scale in Taiwan Nursing Home Residents.

INTRODUCTION: The prevalence of frailty defined by FRAIL-NH varies among different studies in nursing homes, ranging from 19.0% to 75.6%. This study investigated the prevalence of frailty in a nursing home in Taiwan using different diagnostic criteria for frailty. METHODS: The 7-item FRAIL-NH scale was used for assessing frailty. There are 7 components: fatigue, resistance, mobility, incontinence or disease, weight loss, eating style and assistance with dressing. Each item is worth 0, 1, or 2 points for a total score of 14 points. We sorted and summarized the patients, according to the number of variables, into the not frail, frail, and most frail groups. Descriptive analysis was applied to understand the basic attributes of the elderly with different degrees of frailty, the influencing factors of frailty, and the occurrence of frailty. RESULTS: Our final sample included 34 residents. They were aged between 56 and 100 years (mean age 83.91 ± 10.84), and 18 (52.94%) were female. The frail group revealed a higher prevalence of males than of females. The marital status composition of participants was as follows: 2 (5.88%) unmarried, 24 (70.59%) married, and 8 (23.53%) widowed. The mean FRAIL-NH score was 5.79±3.72. CONCLUSIONS: A significant prevalence of frailty defined by FRAIL-NH was observed in a nursing home in Taiwan. Our findings indicate that frailty is an important issue in nursing homes. Further prospective cohort studies using FRAIL-NH evaluation are warranted.

Cross-cultural adaptation and validation of the FRAIL-NH scale for Chinese nursing home residents: A methodological and cross-sectional study.

BACKGROUND: Frailty is a common condition in older adults, and has a particularly high prevalence among nursing home residents. Therefore, it is essential to assess frailty in nursing homes. The FRAIL-NH scale is a brief, quick-to-complete, and user-friendly measurement tool. However, it has not been used in China, and further cross-cultural adaptation and validation need to be undertaken. OBJECTIVES: To cross-culturally adapt and validate the FRAIL-NH scale for Chinese nursing home residents. DESIGN: Methodological and cross-sectional study. SETTING: Twenty-seven nursing homes in Jinan, China. PARTICIPANTS: Older Chinese nursing home residents (n = 353, age ≥60 years, 197 women; 156 men). METHODS: Interviewers obtained data on frailty, demographics, comorbidity, physical function, nutritional status, and self-rated health. The Chinese FRAIL-NH scale version was generated using the translation-backward translation method. Psychometric properties, including internal consistency, test-retest reliability, convergent validity, criterion validity, and diagnosis accuracy were evaluated. RESULTS: The FRAIL-NH scale showed acceptable internal consistency (Cronbach's alpha: 0.67) and satisfactory test-retest reliability within a 1- to 2-week interval (intraclass correlation coefficient: 0.84). As expected, the FRAIL-NH scale was correlated to the validated measurements, presenting convergent validity. Using the frailty phenotype as a reference criterion, the area under the curve was 0.79. The optimal cutoff point for frailty was 2 (sensitivity: 69.90% and 77.33%) in Chinese nursing homes. The FRAIL-NH scale was significantly associated with the frailty phenotype (correlation coefficient = 0.61, P < 0.001), but showed fair agreement with it (kappa = 0.46, p < 0.001). CONCLUSIONS: The FRAIL-NH scale was found to be suitable for frailty measurement with acceptable validity and reliability, and the optimal cutoff point for frailty was 2. The FRAIL-NH scale can be applied in Chinese nursing homes.

Assessing Frailty in Chinese Nursing Home Older Adults: A Comparison between the Frail-NH Scale and Frailty Index.

OBJECTIVE: (1) To establish appropriate FRAIL-NH cutoff points in nursing homes in Mainland China; (2) To compare the FRAIL-NH scale and Frailty Index in assessing frailty prevalence and associated factors in nursing homes. DESIGN: A cross-sectional study. SETTING: Six nursing homes in Changsha, China. PARTICIPANTS: A total of 302 residents aged 60 years or older (mean aged 82.71±8.49, 71.2% female). MEASUREMENTS: Frailty was assessed using the 34-item Frailty Index and the FRAIL-NH scale. RESULTS: The appropriate FRAIL-NH cutoff points to classify frail status and frailest status were 1.5 (87.6% sensitivity, 63.3% specificity) and 7.5 (94.1% sensitivity, 73.4% specificity), respectively. Based on the FRAIL-NH and Frailty Index, 69.5% (48% for frail and 21.5% for frailest), and 66.5% (60.9% for frail and 5.6% for frailest) of residents were at risk of frailty, respectively. There was no statistically significant difference in the total frailty prevalence assessed by FRAIL-NH and Frailty Index (χ2=0.617, P=0.432). The FRAIL-NH Scale is significantly associated with the Frailty Index (correlation coefficient (r) = 0.74, P < 0.001), but there was a Kappa agreement of 0.39 for frailty classification between the FRAIL-NH and Frailty Index, with the Frailty Index classifying a larger number of individuals as frail. When using FRAIL-NH scale, disease and self-reported health status were associated with frail and frailest status while age was just associated with frailest status. regarding the Frailty Index, age, diseases, medications and self-reported health status were associated with frail and frailest status. CONCLUSION: The FRAIL-NH is a simple and effective tool to assess the overall frailty rate in nursing homes, and the Frailty Index may be more suitable capturing the multidimensionality of frailty at an individual level. Careful consideration in the selection of a frailty instrument, based on the intended purpose, is necessary.