Acute-Care Frailty Ladder

Rationale: Hospital care is also an opportunity to identify frailty and to provide interventions and services to reverse or delay progression. However, none of the many frailty indices or “measures” currently available is ideal for deployment in the busy hospital setting and none would meet modern robust psychometric standards for creating legitimate total scores. This study addresses a current gap in the implementation of frailty measures in an acute care setting, which is the need to implement a measure that can serve as an evaluative measure with robust psychometric properties yielding a legitimate total score.

Hypothesis: Items that represent the frailty construct will fit a unidimensional, hierarchical continuum.

Objectives: (1) Estimate, for an in- and out-patient geriatric population, the prevalence and severity of impairment on existing frailty indicators at two points in time over a one month period; (2) estimate the extent to which these frailty indicators form a unidimensional measure with linearized units; and (3) validate the prototype version of the Acute-Care Frailty Ladder in a new sample of older persons receiving hospital care.

Research plan: A prospective study will be conducted on two samples of 200 and 100 seniors receiving in- or out-patient care. To be included, participants must be: (1) 70 years of age or older and (2) community dwelling prior to hospitalization or clinic visit. More than 40 frailty indicators have been identified from our patient and provider focus groups, chart review, literature; and clinical experience. These include performance-based indicators related to mobility, strength, and endurance such as gait speed, balance, functional walking capacity, functional reach, sit-to-stand, and grip strength. A number of patient reported and self-reported outcomes have also been included as frailty indicators coming from well-known legacy measures of basic and
instrumental activities of daily living, symptoms, and health perception. We will comprehensively assess all consenting seniors over the age of 70 years on these indicators at two time points separated by one month. These items will form the item pool for Rasch analysis to identify the extent to which they form a unidimensional measure. The prototype version of the Acute-Care Frailty Ladder will be tested in a new sample of seniors.

Key Findings:

• 27 unique items fit onto the Frailty Ladder forming 58 steps
• 17 self-reported items on physical function and 10 performance tests including one for cognition and two for lung function
• Patient reports of pain, fatigue, mood, and health did not fit; nor did any item representing participation.

Why was this study needed?

Frailty is currently represented as a classification, not frail, pre-frail, or frail, rather than as a quantity to be measured.  To create a measure requires that frailty to be considered something that is reflected by certain capacities that line up in a hierarchical manner from lowest, most frail, to highest most robust.  This study tested the idea that frailty can be measured and not just classified, thus making the estimation of change mathematically valid.

Brief overview of the methodology:

• The objective of this study is to test the extent to which a set of items identified within the frailty concept fit a hierarchical linear model (e.g Rasch model) and form a true measure reflective of the frailty construct.
• A sample of participants was assembled from a community organization for at-risk seniors (n=141), colorectal surgery patients assessed post-surgery (n=47), and hip fracture patients assessed post-rehabilitation (n=46).
• The 234 individuals (age 57 to 97) contributed 348 measurements.
• The frailty construct was defined according to the named domains within commonly used frailty indices and items (n=68) selected to reflect frailty arising from self-report measures and performance-based tests.
• Rasch analysis was used to identify the extent to which the items from the measures formed a unidimensional linear measure.

Potential impact of findings on clinical practice/patient care and how this impact might be measured:

• The Frailty Ladder can be used as a clinical tool to track the status of seniors as they age and/or recover from illnesses or health events and to intervene to maintain robustness
• The Frailty Ladder can be used by seniors and their family members to monitor status and act to maintain robustness
• The Frailty Ladder can be used in research to evaluate the effectiveness of interventions targeting the causes of frailty (consequences of systemic illnesses, poor life style choices, sub-optimal environments)

Remaining knowledge/research gaps:

• Validation of the Frailty Ladder is needed with the opportunity to include variables related to nutritional status, not part of the developmental phase
• Implementation as part of self-management and clinical practice also needs to be evaluated

CFN Webinar (March 14, 2018): Acute-Care Frailty Ladder