frailty phenotype and the frailty index: different instruments for ...

The frailty phenotype is based on a pre-defined set of five criteria exploring the presence/absence of signs or symptoms (i.e. involuntary weight loss, ... 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ArticleNavigation Thefrailtyphenotypeandthefrailtyindex:differentinstrumentsfordifferentpurposes MatteoCesari, MatteoCesari 1Gérontopôle,CentreHospitalierUniversitairedeToulouse,Toulouse,France2INSERMUMR1027,UniversitédeToulouseIIIPaulSabatier,Toulouse,France Addresscorrespondenceto:M.Cesari.Tel:+33(0)561145628;Fax:+33(0)561145640;Email:[email protected] Searchforotherworksbythisauthoron: OxfordAcademic PubMed GoogleScholar GiovanniGambassi, GiovanniGambassi 3CentroMedicinadell'Invecchiamento,UniversitàCattolicadelSacroCuore,Roma,Italy Searchforotherworksbythisauthoron: OxfordAcademic PubMed GoogleScholar GaborAbellanvanKan, GaborAbellanvanKan 1Gérontopôle,CentreHospitalierUniversitairedeToulouse,Toulouse,France2INSERMUMR1027,UniversitédeToulouseIIIPaulSabatier,Toulouse,France Searchforotherworksbythisauthoron: OxfordAcademic PubMed GoogleScholar BrunoVellas BrunoVellas 1Gérontopôle,CentreHospitalierUniversitairedeToulouse,Toulouse,France2INSERMUMR1027,UniversitédeToulouseIIIPaulSabatier,Toulouse,France Searchforotherworksbythisauthoron: OxfordAcademic PubMed GoogleScholar AgeandAgeing,Volume43,Issue1,January2014,Pages10–12,https://doi.org/10.1093/ageing/aft160 Published: 16October2013 Articlehistory Received: 27May2013 Accepted: 26July2013 Published: 16October2013 PDF SplitView Views Articlecontents Figures&tables Video Audio SupplementaryData Cite Cite MatteoCesari,GiovanniGambassi,GaborAbellanvanKan,BrunoVellas,Thefrailtyphenotypeandthefrailtyindex:differentinstrumentsfordifferentpurposes,AgeandAgeing,Volume43,Issue1,January2014,Pages10–12,https://doi.org/10.1093/ageing/aft160 SelectFormat Selectformat .ris(Mendeley,Papers,Zotero) .enw(EndNote) .bibtex(BibTex) .txt(Medlars,RefWorks) Downloadcitation Close PermissionsIcon Permissions Share Email Twitter Facebook More NavbarSearchFilter ThisissueAllAgeandAgeing AllJournals MobileMicrositeSearchTerm Search SignIn Close searchfilter Thisissue AllAgeandAgeing AllJournals searchinput Search AdvancedSearch SearchMenu Abstract Theintegrationoffrailtymeasuresinclinicalpracticeiscrucialforthedevelopmentofinterventionsagainstdisablingconditionsinolderpersons.Thefrailtyphenotype(proposedandvalidatedbyFriedandcolleaguesintheCardiovascularHealthStudy)andtheFrailtyIndex(proposedandvalidatedbyRockwoodandcolleaguesintheCanadianStudyofHealthandAging)representthemostknownoperationaldefinitionsoffrailtyinolderpersons.Unfortunately,theyareoftenwronglyconsideredasalternativesand/orsubstitutables.Thesetwoinstrumentsareindeedverydifferentandshouldratherbeconsideredascomplementary.Inthepresentpaper,wediscussaboutthedesignsandrationalsofthetwoinstruments,proposingthecorrectwaysforhavingthemimplementedintheclinicalsetting. frailty,phenotype,screening,disability,olderpeopleAlthoughthetheoreticalfoundationsofthefrailtysyndromearewellestablishedinliteratureandtheconceptalmostuniversallyaccepted,itspracticaltranslation(especiallyintheeverydayclinicallife)remainscontroversial[1].Theintegrationoffrailtymeasuresinclinicalpracticeiscrucialforthedevelopmentofinterventionsagainstage-relatedconditions(inparticular,disability)inolderpersons[2].Multipleinstrumentshavebeendevelopedoverthelastyearsinordertocapturethisgeriatric‘multidimensionalsyndromecharacterizedbydecreasedreserveanddiminishedresistancetostressors’[3]andrenderitobjectivelymeasurable.Friedetal.[4]initiallyhypothesisedsomecoreclinicalpresentationsoffrailty,whichwerethenoperationalisedintotheinstrument(i.e.thefrailtyphenotype)validatedintheCardiovascularHealthStudy[5].Subsequently,Rockwoodetal.[6]usedtheCanadianStudyofHealthandAgingtodevelopandvalidatetheso-calledFrailtyIndex.Duringthelastfewyears,severalotherinstrumentstomeasurefrailtyhavebeenproposed,frequentlybuildingonthesetwomodels[7–9].Indeed,thefrailtyphenotypeandtheFrailtyIndexhavemonopolisedtheattentionofthescientificcommunity,withapolarisationintodistinct‘schoolsofthought’.Itisnotuncommontohearaboutthepreferencethataclinicianoraresearcherhasforoneortheotherinstrument.However,itisinappropriatetoconsiderthefrailtyphenotypeandtheFrailtyIndexasalternativesand/orsubstitutables.Thesetwoinstrumentsaredifferentandshouldratherbeconsideredascomplementary.TheirmaincharacteristicsanddifferencesarepresentedinTable1. Table1.MaincharacteristicsofthefrailtyphenotypeandtheFrailtyIndexFrailtyphenotype . FrailtyIndex . Signs,symptoms Diseases,activitiesofdailyliving,resultsofaclinicalevaluation Possiblebeforeaclinicalassessment Doableonlyafteracomprehensiveclinicalassessment Categoricalvariable Continuousvariable Pre-definedsetofcriteria Unspecifiedsetofcriteria Frailtyasapre-disabilitysyndrome Frailtyasanaccumulationofdeficits Meaningfulresultspotentiallyrestrictedtonon-disabledolderpersons Meaningfulresultsineveryindividual,independentlyoffunctionalstatusorage Frailtyphenotype . FrailtyIndex . Signs,symptoms Diseases,activitiesofdailyliving,resultsofaclinicalevaluation Possiblebeforeaclinicalassessment Doableonlyafteracomprehensiveclinicalassessment Categoricalvariable Continuousvariable Pre-definedsetofcriteria Unspecifiedsetofcriteria Frailtyasapre-disabilitysyndrome Frailtyasanaccumulationofdeficits Meaningfulresultspotentiallyrestrictedtonon-disabledolderpersons Meaningfulresultsineveryindividual,independentlyoffunctionalstatusorage  Openinnewtab Table1.MaincharacteristicsofthefrailtyphenotypeandtheFrailtyIndexFrailtyphenotype . FrailtyIndex . Signs,symptoms Diseases,activitiesofdailyliving,resultsofaclinicalevaluation Possiblebeforeaclinicalassessment Doableonlyafteracomprehensiveclinicalassessment Categoricalvariable Continuousvariable Pre-definedsetofcriteria Unspecifiedsetofcriteria Frailtyasapre-disabilitysyndrome Frailtyasanaccumulationofdeficits Meaningfulresultspotentiallyrestrictedtonon-disabledolderpersons Meaningfulresultsineveryindividual,independentlyoffunctionalstatusorage Frailtyphenotype . FrailtyIndex . Signs,symptoms Diseases,activitiesofdailyliving,resultsofaclinicalevaluation Possiblebeforeaclinicalassessment Doableonlyafteracomprehensiveclinicalassessment Categoricalvariable Continuousvariable Pre-definedsetofcriteria Unspecifiedsetofcriteria Frailtyasapre-disabilitysyndrome Frailtyasanaccumulationofdeficits Meaningfulresultspotentiallyrestrictedtonon-disabledolderpersons Meaningfulresultsineveryindividual,independentlyoffunctionalstatusorage  Openinnewtab Thefrailtyphenotypeisbasedonapre-definedsetoffivecriteriaexploringthepresence/absenceofsignsorsymptoms(i.e.involuntaryweightloss,exhaustion,slowgaitspeed,poorhandgripstrength,andsedentarybehaviour)[5].Thenumberofcriteria(a6-levelordinalvariablerangingfrom0to5)iscategorisedintoa3-levelvariabledepictingrobustness(noneofthecriteria),pre-frailty(oneortwocriteria)andfrailty(threeormorecriteria).Thefrailtyphenotypecanbeappliedatthefirstcontactwiththesubjectanddoesnotneedapreliminaryclinicalevaluation.Therefore,itmaywellservefortheinitialriskstratificationofthepopulationaccordingtodifferentprofiles(i.e.robust,pre-frailandfrail).Yet,thefrailtyphenotypedoesnotprovideanyindicationaboutpreventiveortherapeuticinterventionstoputinplace.Bybeingcomposedofverygeneralsignsorsymptoms,itcanmainlyrisean‘alert’aboutapossibleproblem.Suchalertcannotgenerateimmediatepreventiveortherapeuticinterventionsbecausenoinformationisavailableabouttheunderlyingcausesoftheconditionofrisk.Forexample,itwouldbeimpropertotreatinvoluntaryweightlossorslowgaitspeedwithoutknowingtheunderlyingcausalconditions.Onlythesubsequentcomprehensivegeriatricassessment(i.e.themultidimensional,interdisciplinarydiagnosticprocessevaluatingtheoverallhealthstatusofafrailolderpersoninordertodevelopacoordinatedandintegratedintervention)willprovidetherequiredinformationsupportingspecificactions.Althoughthefrailtyphenotypeiscomposedbysimpletasks,itsadministrationandmeaningfulnessmaysometimesresultproblematic.Theevaluationofmusclestrengthandgaitspeedisnotalwaysdoable,especiallyinprimarycare,duetothelackofdynamometersand/orspace/timetoassessgaitspeed.Moreover,specificconditions(suchasdisabilityorcognitiveimpairment)mayaffectthereliabilityorclinicalutilityofthefrailtyphenotyperesults.Inparticular,disablingconditionsmayaffectthepredictivevalueofthephenotypefornegativehealth-relatedeventsduetoasortof‘ceilingeffect’[10].Furthermore,theinstrumentmaybecomeunfeasibleiftobeappliedtolargepopulations.Inthiscase,therequiredcontactbetweentheindividualandtheassessorformeasuringthefrailtyphenotypemayrenderalternativescreeningtools(e.g.self-reportedquestionnaires[11])tobepreferredinthefirstestimation/screeningoftheindividual'sriskprofile.Conversely,theFrailtyIndexiscomposedbyalongchecklistofclinicalconditionsanddiseases.The70itemsoftheoriginalversionarenottobeconsideredasafixedsetofvariables.Theconceptualdesignofthisindexdeemsasmoreimportantthedeficitaccumulation.Ithasbeenreportedthatestimatesofriskarerobustwhenaminimumof50itemsareconsidered,butshorterversions(aslowas20conditions)havealsobeenexplored[12].AlthoughtheFrailtyIndexhassometimesbeencategorisedinordertomirrordichotomousconditions(e.g.robustnessversusfrailty)[13],itsmajordistinctivetraitresidesinitscontinuousnature.ItisevidentthattheFrailtyIndexisinapplicableatthefirstcontactwithanindividualbecauseitcanonlybegeneratedafter(orinparallelwith)acomprehensivegeriatricassessment.Oncecompleted,theFrailtyIndexthenbecomesextremelyinformativeforthecontinuousfollow-upofthesubject.Infact,theFrailtyIndexislikelymoresensitivetomodificationsthanthecategoricalfrailtyphenotype[1].Thus,theFrailtyIndexmaybeamoreusefultooltoascertaintheeffectivenessofanyinterventionandtodescribethehealthstatustrajectoriesovertime.Thecontinuousvariablealsoallowstoavoidtheriskofmisclassificationsduetothearbitrarydecisionsrequiredfordefiningthresholdsofrisk(i.e.cut-points).Nevertheless,theclinicalimplementationofaparameteralwayspassesthroughitscategorisationintoclassesofrisk,differentiatingnormalityfromabnormality.ThecategorisationintogroupsofriskofthefrailtyphenotypemakesitclosertothedefinitionofastandardclinicalconditionthantheFrailtyIndex.Inaclinicalworldincreasinglydominatedbytechnologies,itcanbeenvisaged(butyettobefield-tested)thatacomprehensivegeriatricassessmentembeddedintoanelectronichealthrecordwouldautomaticallygenerateaFrailtyIndexservingasreferenceforsubsequentassessments.Lastbutnotleast,itcannotbeignoredtwomajorconceptualdifferencesatthebasisofthetwoinstruments:Relationshipbetweenfrailtyandnosographicallyclassifiedconditions.Asmentioned,thefrailtyphenotypeisbasedontheevaluationofsignsandsymptoms.Thismeansthat,accordingtoFriedetal.[5,14],frailtymaytheoreticallyexistevenintheabsenceofnosographicallyclassifiedconditions.Undersuchperspective,thefrailtyphenotypeindeeddepictsanovelage-relatedconditionofspecialinterestforsystembiology[15].Conversely,theFrailtyIndexislargelybasedonnosographicallyclassifiedconditions.Itdescribesariskprofileclosertotheonemeasuredbytheclinician,potentiallydefiningaconditionofvulnerabilitydifferentfromthatisolatedbythephenotypeoffrailty.Relationshipoffrailtywithdisability.Intheirstudyvalidatingthephenotype,Friedetal.[5]supportthehypothesisthatfrailtycausesdisabilityindependentlyof(sub)clinicaldiseases.Theyexplainthat‘thesyndromeoffrailtymaybeaphysiologicprecursorandetiologicfactorindisability’.Thismeansanimplicitidentificationoffrailtyasakeyfactorforthedesignandconductionofinterventionsagainstincidentdisability.Therefore,thefrailtyphenotypefindsitsidealapplicationinnon-disabledoldersubjects.Ontheotherhand,theFrailtyIndexincludesitemsoffunctionaldisability(e.g.problemsgettingdressed,problemswithbathingandimpairedmobility)initscomputation[6].Inotherwords,theFrailtyIndexdoesnotmakeacleardifferentiationbetweenfrailtyanddisability.Itismoreinterestedatobjectivelyestimatingtheamountofaccumulateddeficits/functionallosses,whichevertheyare.Theseconceptualdifferencesbetweenthetwoinstrumentsobviouslyandconsequentlydifferentiatethetargetpopulationstowhichtheymightbeapplied.Asmentioned,whilewemaymeaningfullyestimatetheFrailtyIndexineveryindividual,thefrailtyphenotypemaylosesomeofitsclinicalrelevancewhenassessedinolderpersonsalreadyexperiencingdisability.Tosummarise,thefrailtyphenotypecategoricallydefinesthepresence/absenceofaconditionofriskforsubsequentevents(mostspecifically,disability).Bydifferentiatinganormal(i.e.robustness)versusanabnormal(i.e.frailty)status,thefrailtyphenotypemayfacilitatetheimplementationofthefrailtyconceptintoclinicalpractice.Itprovidestheclinical-friendlydichotomousvariableonwhichdecidingthepossibleneedofadaptedcareand/orinterventions.Differently,theFrailtyIndexactsasmeasureoftheorganismcapacitytoaccumulatedeficits.Ittellsushowmanyclinicalconditionsarepresentandconcuratexhaustingreserves.Thus,theFrailtyIndexseemstoactasanobjectivemarkerofdeficitsaccumulation.Currentevidenceaboutarelevantconvergencebetweenthetwoprincipalmodelsoffrailtyshouldbetakenasameasureofthevalidityoftheconceptoffrailty[13].Likewise,itisevidentthatthetwomeasurementscannotbeconsideredasequivalent.Theyfindtheirusefulnessatdistincttimesintheevaluationofanindividualandassuchtheyservedifferentpurposes.Theuseofaninstrumentshouldalwaysbeconformtotheaimsforwhichitwasdesignedwithrespectforitscharacteristics.Thecorrectandcombined/sequentialuseofthetwoinstrumentsisadvisablebecausetheyprovidedistinctandcomplementaryclinicalinformationabouttheriskprofileofanolderperson.Theonlywaytoprevent/delaydisablingconditionsisthroughtheimplementationofearlyactionsinpersonspresentinganincreasedriskprofile.Geriatriciansandgeneralpractitionersshouldfeelthemselvesmoreresponsibleforthetasksofmeasuringfrailtyinolderpersons,raisingawarenessabouttheburdensofage-relatedanddisablingconditionsamongtheirpatientsandpromotingprimarypreventiveactionsinthecommunity(incollaborationwithpublichealthcareauthorities).KeypointsThefrailtyphenotypeandtheFrailtyIndexarefrequentlyperceivedasalternativesalthoughdesignedfordifferentpurposes.Thefrailtyphenotypemaybemoresuitableforanimmediateidentificationofnon-disabledeldersatriskofnegativeevents.TheFrailtyIndexmaysummarisetheresultsofacomprehensivegeriatricassessmentprovidingamarkerofdeficitsaccumulation.Thetwoinstrumentshavedifferentpurposesandaretobeconsideredcomplementaryintheevaluationoftheolderperson.References 1CleggA, YoungJ, IliffeS, RikkertMO, RockwoodK. Frailtyinelderlypeople, Lancet, 2013, vol. 381 (pg. 752-62)GoogleScholarCrossrefSearchADSPubMedWorldCat 2SubraJ, Gillette-GuyonnetS, CesariM, OustricS, VellasB. Theintegrationoffrailtyintoclinicalpractice:preliminaryresultsfromthegérontopôle, JNutrHealthAging, 2012, vol. 16 (pg. 714-20)GoogleScholarCrossrefSearchADSPubMedWorldCat 3Rodríguez-MañasL, FéartC, MannG, etal. Searchingforanoperationaldefinitionoffrailty:adelphimethodbasedconsensusstatement.Thefrailtyoperativedefinition-consensusconferenceproject, JGerontolABiolSciMedSci, 2012, vol. 68 (pg. 62-7)GoogleScholarCrossrefSearchADSPubMedWorldCat 4FriedLP, WalstonJ. HazzardWR, BlassJP, EttingerWH, HalterJB, OuslanderJG. Frailtyandfailuretothrieve, PrinciplesofGeriatricMedicineandGerontology, 1998NewYorkMcGraw-Hill(pg. 1387-402)GoogleScholarGooglePreviewOpenURLPlaceholderTextWorldCatCOPAC 5FriedLP, TangenCM, WalstonJ, etal. Frailtyinolderadults:evidenceforaphenotype, JGerontolABiolSciMedSci, 2001, vol. 56 (pg. M146-56)GoogleScholarCrossrefSearchADSPubMedWorldCat 6RockwoodK, SongX, MacKnightC, etal. Aglobalclinicalmeasureoffitnessandfrailtyinelderlypeople, CMAJ, 2005, vol. 173 (pg. 489-95)GoogleScholarCrossrefSearchADSPubMedWorldCat 7EnsrudK, EwingSK, TaylorBC, etal. Comparisonof2frailtyindexesforpredictionoffalls,disability,fractures,anddeathinolderwomen, ArchInternMed, 2008, vol. 168 (pg. 382-9)GoogleScholarCrossrefSearchADSPubMedWorldCat 8GobbensRJ, vanAssenMA, LuijkxKG, Wijnen-SponseleeMT, ScholsJM. TheTilburgFrailtyIndicator:psychometricproperties, JAmMedDirAssoc, 2010, vol. 11 (pg. 344-55)GoogleScholarCrossrefSearchADSPubMedWorldCat 9BuchmanAS, BoylePA, WilsonRS, TangY, BennettDA. FrailtyisassociatedwithincidentAlzheimer'sdiseaseandcognitivedeclineintheelderly, PsychosomMed, 2007, vol. 69 (pg. 483-9)GoogleScholarCrossrefSearchADSPubMedWorldCat 10WouF, GladmanJR, BradshawL, FranklinM, EdmansJ, ConroySP. Thepredictivepropertiesoffrailty-ratingscalesintheacutemedicalunit, AgeAgeing, 2013, vol. 42 (pg. 776-81)GoogleScholarCrossrefSearchADSPubMedWorldCat 11CesariM, DemougeotL, BoccalonH, VellasB. PrevalenceoffrailtyandmobilitylimitationinaruralsettinginFrance, JFrailtyAging, 2012, vol. 1 (pg. 169-74)GoogleScholarPubMedOpenURLPlaceholderTextWorldCat 12RockwoodK, MitnitskiA. Howmightdeficitaccumulationgiverisetofrailty?, JFrailtyAging, 2012, vol. 1 (pg. 8-12)GoogleScholarPubMedOpenURLPlaceholderTextWorldCat 13RockwoodK, AndrewM, MitnitskiA. Acomparisonoftwoapproachestomeasuringfrailtyinelderlypeople, JGerontolABiolSciMedSci, 2007, vol. 62 (pg. 738-43)GoogleScholarCrossrefSearchADSPubMedWorldCat 14FriedLP, FerrucciL, DarerJ, WilliamsonJD, AndersonG. Untanglingtheconceptsofdisability,frailty,andcomorbidity:implicationsforimprovedtargetingandcare, JGerontolABiolSciMedSci, 2004, vol. 59 (pg. 255-63)GoogleScholarCrossrefSearchADSPubMedWorldCat 15KuchelG. Frailty,allostaticload,andthefutureofpredictivegerontology, JAmGeriatrSoc, 2009, vol. 57 (pg. 1704-6)GoogleScholarCrossrefSearchADSPubMedWorldCat  ©TheAuthor2013.PublishedbyOxfordUniversityPressonbehalfoftheBritishGeriatricsSociety.Allrightsreserved.ForPermissions,pleaseemail:[email protected] Topic: aging phenotype cardiovascularhealthstudy frailty olderadult friedfoods IssueSection: Commentary Downloadallslides Comments 1Comment Comments(1) Dominantfrailtyassessmentmethodsareunsuitableforclinicalpurposes 20February2014 ReneJ.Melis(withHenkJ.Schers,MarcelG.M.OldeRikkert) seniorresearcher,DepartmentofGeriatricMedicine,RadboudUniversityMedicalCenter Thestatementthat"different[frailty]instruments[serve]... differentpurposes"(1)offersanewperspectiveinandwayoutofthe frailtycontroversy.Recognizingthattwopeoplemayhavedifferent conceptsinmindandbothcallitfrailty,theyrightlyadvocatetobe explicitaboutthepurposeforwhichoneusesafrailtyconstruct. However,wedisagreehowtheyascribeclinicalpurposestoFrailty PhenotypeandFrailtyIndex,asbothwereprimarilydevelopedinthe researchrealmandnotatallforclinicalapplication. Fromanapplied,clinicalperspectivethemostimportantuseof frailtyistotriageamongolderpeoplewhoneedswhatserviceresponse. Weknowthatolderpeopleareaveryheterogeneouspopulationintermsof health,function,andcapabilities.Likewise,theserviceresponseshould alsogofromcareasusual(leavingtheinitiativetoengageaservice responsewiththeadultinvolved)toproactivelyorganized multidisciplinary,integratedcare.Clinically,themeritoffrailtyis thatitisanintegrative,multidimensionalandcomprehensiveconceptthat canhelptomapthesegroupsandtotailorserviceresponsesaswas rightlypointedoutinaneditorialinthesameissueofAgeandAgeing (2). Althoughtriageisthepurposethatraisedinterestinfrailtyinthe firstplace(3),itisalsothepurposeforwhichthedominantly epidemiology-basedinstrumentsareleastsuited.TheFrailtyPhenotypeis aphysicallymediated,pre-disabilitysyndrome,andthustoonarrowly defined.Second,frailtyonbothinstrumentsindicatehigherrisksfor negativeoutcomes,buttheseincreasedrisksalonedonotequateto derivingvaluefromalternativeserviceresponsessuchasmoreproactive monitoringorevenfullyintegratedcare.Tobevaluableinclinical practice,triageinelderlycareshouldbefuelledbytheclinical perspective:whatarepotentialindividualbenefitsifwetreatthese patientsdifferently?Suchanevidence-basedinstrumentisclearlymissing (4). Tothisend,wehavedevelopedasteppedapproachrootedinclinical practice,insteadofinepidemiology:theEASY-CareTwostepOlderpeople Screening(TOS)(5).Inthefirststep,thegeneralpractitioner(GP)maps allpersonsover70sregisteredinhispracticeonthebasisofprior knowledge.Onlypersonsconsideredfrailorinwhompriorknowledgeis insufficienttomakeajudgmentaregearedupforfurtherfrailty assessmentthroughaprimarycarecomprehensivegeriatricassessment.The GP'sclinicalappraisalisdecisiveinthefrailtydecisionandtogether withinputfromthepatientandcaregiversguidestheserviceresponse needed. Thepurposeoffrailtytoidentifytargetgroupsfor(more) integratedcareiscurrentlyunderservedbytheavailablefrailty instruments.Anew,steppedmethodmayservethisspecificpurposeina clinicallymeaningful,feasibleandvalidway(5). 1. CesariM,GambassiG,vanKanGA,VellasB.Thefrailtyphenotype andthefrailtyindex:differentinstrumentsfordifferentpurposes.Age Ageing.2014;43(1):10-2.Epub2013/10/18. 2. GordonAL,MasudT,GladmanJR.Nowthatwehaveadefinitionfor physicalfrailty,whatshapeshouldfrailtymedicinetake?AgeAgeing. 2014;43(1):8-9.Epub2013/10/24. 3. FederalCouncilontheAging(U.S.).Publicpolicyandthefrail elderly:astaffreport,December1978.Washington,D.C.:U.S.Dept.of Health,Education,andWelfare,OfficeofHumanDevelopmentServices, FederalCouncilon[the]Aging;1979.viii,170p.p. 4. DeLepeleireJ,DegryseJ,IlliffeS,MannE,BuntinxF.Family physiciansneedeasyinstrumentsforfrailty.AgeAgeing.2008;37(4):484; authorreply-5.Epub2008/06/03. 5. vanKempenJA,SchersHJ,MelisRJ,OldeRikkertMG.Construct validityandreliabilityofatwo-steptoolfortheidentificationof frailolderpeopleinprimarycare.JClinEpidemiol.2014;67(2):176-83. Epub2013/11/06. ConflictofInterest: Nonedeclared Submittedon20/02/20147:00PMGMT Addcomment Closecommentformmodal Iagreetothetermsandconditions. Youmustacceptthetermsandconditions. 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