Measuring Frailty A comparison of the frailty phenotype and frailty index for the prediction of all-cause mortality James Nazroo Alan Marshall, Kris Mekli and Neil Pendleton

Background  Specific definitions and models of frailty are contested  Broad agreement that frailty is a non-specific state reflecting age-related declines in multiple systems, which lead to adverse outcomes (mortality, hospitalisation)  Two common approaches to characterise frailty:  Frailty index (Rockwood and colleagues)  Frailty phenotype (Fried and colleagues)  Compare the two approaches and, in particular, their success in predicting all cause mortality  And how well do they perform compared with other markers of risk?

The English Longitudinal Study of Ageing (  A panel study of people aged 50 and older, recently finished our sixth wave of data collection, with additional wave 0 data available  Sample at wave 1 (2002) was approximately 11,400 people born before 1 st March 1952 who were in the private household sector. Drawn from Health Survey for England (wave 0).  Face to face interview every two years since 2002, with a biomedical assessment carried out by a nurse every four years.  Those incapable of doing the interview have a proxy interview.  End of life interviews are carried out with the partners or carers of people who died after wave 1.  Detailed content on: demographics, health, performance, biomarkers, wellbeing, economics, housing, employment, social relationships, social civic and cultural participation, life history.  Sister study to HRS, SHARE, KLOSA, CHARLS, etc.

Frailty Index (FI)  Based on accumulation of ‘deficits’ (from 30 items)  Activities of Daily Living  Cognitive function  Chronic diseases  CVD  Depression/mental health  Poor eyesight/hearing  Falls, fractures and joint replacements  0-1 scale for each component  Calculate the proportion of deficits held (so 0-1 scale)  Can be divided into three categories  Robust (0-0.12)  Pre-frail ( )  Frail (>0.21)

Frailty Phenotype (FP): Fried et al  Aim: to establish a standardized definition of frailty  5 items:  Sarcopenia: unintentional weight loss, > 8% bodyweight  Exhaustion: had both ‘everything they did was an effort’ and ‘could not get going much of the time’, during the past week  Low physical activity: no work and no other physical activities  Slowness: timed walk in the slowest 20% of population  Weakness: grip strength in the weakest 20% of population  Outcome  Robust phenotype: positive for 0 item  Pre-frail phenotype: positive for 1-2 items  Frail phenotype: positive for 3-5 items

Analysis  Those aged sixty or older (walking speed)  Cumulative distribution of Frailty Index score for each Frailty Phenotype category (‘robust’, ‘pre-frail’ and ‘frail’)  Kaplan-Meier survival plots  Cox proportional hazard models  Test association between Frailty Index and Frailty Phenotype (at wave 2) and all cause mortality  Unadjusted model and then adjusted for demographics and then key risk factors (education, wealth, bmi, smoking)  Compare goodness of fit of models, and compare fit with models using self-assessed health and wealth

0.21 used as a cut-off for dichotomous frailty variable 30% frail in wave 1 Frailty index: distribution (wave 1)

Descriptives P value compares the survived and died groups (t-test and chi squared test)

Males Cumulative distribution Females Frailty index Frail Pre-frail Robust Frail Pre-frail Robust Frailty Index cumulative distribution by Frailty Phenotype

Kaplan-Meier survival estimates - Males Blue = Robust group. Red = Pre-frail group. Green = Frail group Frailty IndexFrailty Phenotype

Kaplan-Meier survival estimates - females Blue = Robust group. Red = Pre-frail group. Green = Frail group Frailty IndexFrailty Phenotype

Cox survival model - results Model 1 controls for age and sex. Model 2 controls for age, sex, education, wealth, smoking, couple

Cox survival model: Health and wealth Model 1 controls for age and sex. Model 2 controls for age, sex, education, (wealth), smoking, couple

Conclusions  Prediction of mortality over an eight year period for older people (aged 60+) living in the community:  Comparable results for Frailty Index and Frailty Phenotype  Comparable results for self-assessed health and wealth  Choice of measure might reflect the particular setting  Frailty Phenotype advantageous in clinical setting: detailed longitudinal ‘diagnostic’ measure  Frailty index useful in community environment: checklist approach