Abstract
Background
The 29-item Frail-Physical, Psychological and Social (Frail-PPS) and the 14-item Frailty Assessment Measure (FAM) were developed in Singapore to identify risk of frailty among community dwelling older adults and validated for use among hospitalised older adults.
Objectives
This study aimed to establish the interrater reliability and feasibility of the two screening tools ‒ FAM and Frail-PPS, for assessing frailty among hospitalized older adults.
Methods
The FAM and Frail-PPS were administered during the initial nursing assessment by nurses to 62 patients aged 65 years and older within 24 h of admission. Interrater reliability, convergent validity and intraclass correlation coefficients (ICCs) were established. Feasibility was determined by the time of administration.
Results
ICCs for Frail-PPS and FAM were 0.95 and 0.95 respectively. A positive correlation was established (r = 0.97). The administration time for Frail-PPS averaged 6.7 min, and 3.3 min for FAM.
Conclusions
The FAM, with its high reliability and convergent validity, as well as shorter administration time, may be the preferred screening tool for use in acute care settings.
Introduction
Older adults admitted to hospitals are at high risk of functional decline and often have pre-existing frailty, which often goes unrecognised on admission. 1 Systematic screening of these patients for frailty at admission allows quick and timely identification and implementation of interventions that may prevent or reduce the potential complicating effects of frailty. 2 Frailty is a multifactorial clinical syndrome associated with increased vulnerability for adverse health outcomes such as falls, decreased functional independence, lower quality of life, prolonged hospital stays and increased mortality.3–7 Adoption of an effective screening tool enables the integration of regular screening and documentation into daily practices in the acute care setting, which also increase the awareness among the health care team of potential complications and risks associated with frailty.
The need to assess frailty in the hospitalized population is undisputed, but reliable tools for doing so that meet the needs of health care professionals and benefit patients are currently lacking. The ideal frailty screening tool needs to be practical and clinically relevant, accurately identify patients who are at high risk of functional decline, and at the same time minimize health care professional and patient burden. More research was also recommended to provide more evidence in the areas of early detection of pre-frailty and frailty among the older adults. 8
Background
Early identification of frailty upon admission may help improve the quality of care for older adults in the acute care setting. Multiple screening tools to identify frail older adults have been developed for use in daily practice. However, these screening tools are based on different frailty models with varied operational definitions of frailty. Currently, there is no known gold standard for frailty models or for frailty screening tools.
A recent review reported screening tools which are frequently used in acute care to identify older adults who are at risk of frailty and adverse outcomes. 9 The 14 screening tools reported in the systematic reviews and umbrella reviews showed variable sensitivity (21%–94%) and specificity (39%–95.6%) for the reviewed screening tools - fewer studies had evaluated the reliability component. 9
In addition, for a tool to be deemed useful and feasible to be implemented in the clinical setting, it is imperative that it does not take too much time to complete and can be administered easily by different healthcare professionals caring for the patients. 10 Feasibility of the screening tools is a key element which affects the adoption rate of frailty screening, however is not reported in most studies. 9 The Asia-Pacific Clinical Practice Guidelines for the Management of Frailty has also highlighted the importance of adapting the management guidelines to the local context to identify older adults at risk of frailty with a validated screening tool. 11 In the recent National Frailty Strategy Policy published locally, the Clinical Frailty Scale (CFS) was selected as the national frailty screening tool used in the Singapore community settings. 8 According to Rockwood and Theou, 12 the CFS is a 9-point scale used to evaluate the overall level of fitness or frailty of an older adults, which is largely based on the clinical judgement of a health care professional. This requires much training of the health care professionals to generate accurate and reliable observations of the older adults’ mobilisation, physical activity and ability, including their ability to carry out daily living tasks independently. 13 It was vital to have consistent grading scores among different health care professionals categorising the older adults to the different categories of fitness and frailty level.
To address the highlighted limitations of available tools, a new screening tool was developed: the Frail-Physical, Psychological and Social (Frail-PPS). 14 The 29-item Frail PPS was first developed to predict adverse health outcomes or frail outcomes among community-dwelling older individuals. 14 The Frail-PPS was further revised to a 14-item Frailty Assessment Measure (FAM), which included age, sex and 12 physical frailty items from Frail-PPS. 15 The FAM had a similar predictive validity as the Frail-PPS in determining frail outcomes among those in the community, thus was preferred given its similar accuracy and shorter administration time. 15 The sensitivity and specificity of the Frail-PPS and FAM were further evaluated in the acute care setting to identify older adults who were at risk of frailty. 16 It is uncertain whether these screening tools are sufficiently reliable and feasible to be used in the acute care setting to assess hospitalised older adults’ risk of frailty. The current study introduced the Frail-PPS and FAM in the acute care hospital setting as a routine initial assessment upon patients’ admission and sought to determine the interrater reliability and feasibility of the two tools.
The study
Aim
To establish the interrater reliability and feasibility of the two screening tools ‒ FAM and Frail-PPS, for assessing frailty among hospitalized older adults.
Study design
A cross-sectional study was conducted.
Participants
Patients aged 65 years and older who were admitted via the Department of Emergency Medicine (DEM) to inpatient wards in an acute tertiary hospital in Singapore from September 2019 to February 2020 were recruited. Patients were excluded if they were admitted to intensive care units, transferred from another hospital, diagnosed with a terminal illness, diagnosed with cognitive impairment, diagnosed with dementia, admitted for a stroke or if length of stay was shorter than 48 h. 17
Data collection and instruments
Eligible patients who fit the inclusion criteria were screened using the two screening tools by the nurses from three inpatient wards (one surgical and two medical inpatient wards). A total of 12 nurses with four from each of the participating wards underwent a briefing session and were trained on the use of the two screening tools prior to the study to ensure they were confident in the use of the tools. Patients’ sociodemographic and clinical information, including gender, age, race, education level, marital status, body mass index (BMI) and admitting discipline (medical or surgical) were documented.
Interrater reliability was assessed within 24 h of patients’ admission when the ward nurse reviewed the patient during the routine initial nursing assessment. The Frail-PPS and FAM were independently administered within a 1-h interval by two nurses. The ward nurses were blinded from each other’s frailty screening scores. The ward nurses were asked to place the completed survey forms in an enclosed box placed in a secure location in the ward office, which were collected daily by the study team. They were also briefed to keep their screening scores confidential from other nurses. With respect to the efficiency of the different screening tools, a stopwatch was used to measure feasibility by recording the time required to administer the Frail-PPS and FAM in the sample.
A sample size of minimum 50 patients with two nurse observations per patient was estimated to be required to achieve 86% power to detect an intraclass correlation of 0.85 under the alternative hypothesis when the intraclass correlation under the null hypothesis is 0.70 using an F-test at a significance level of 0.05. 18 This is in accordance with α = 0.05 and β = 0.143. A total of 62 patients were included in this study.
The screening instruments
The Frail-PPS and FAM were selected because of the interest of this pragmatic study to test the two instruments in the local acute care context, and which had previously been utilised in the community settings. These two tools have also been validated in the acute care setting among the hospitalized older adults. (i) Frail-Physical, Psychological and Social (Frail-PPS)
Frail-PPS contains 31-items which is used to determine frailty among the older adults living in the community. 14 The Frail-PPS consists of three domains: (a) physical frailty, measured by the body mass index (BMI), reduced mobility (number of mobility limitations 0–9), weak handgrip strength, and the number of chronic physical health conditions (0–5); (b) psychological frailty, measured by reduced cognition function (10-item Short Portable Mental Status Questionnaire, SPMSQ score 0–10, higher score reflect lower cognition function) 1; 19 and (c) social frailty, measured by weak social network (6-item Lubben social network scale score 0–30, higher score reflect lower social network) 20 and inadequate perceived financial adequacy (1item, score range 0–1, with 1 reflecting difficulty to meet expenses). There are three categories of scoring with Frail-PPS, namely robust (score <0.41), pre-frail (score ≥0.41 and ≤0.83) and frail (score >0.83). Higher Frail-PPS scores indicated higher levels of frailty.
The reported method of the handgrip strength included the average of two measurements of the dominant hand or the average of the two measurements of both hands.
15
The device used for the handgrip strength measurement was the spring-based dynamometer. The handgrip strength rank scores ranged from 20 to 1, with a higher rank indicating weaker handgrip strength. The reported AUC for the composite adverse health outcome was 0.75.
14
(ii) Frailty Assessment Measure (FAM)
FAM is a 14-item subset of Frail-PPS, containing only the physical frailty domain, which is measured by the BMI, reduced mobility, weak handgrip strength, and the number of chronic physical health conditions. 15 There are three categories of scoring with FAM including robust (score <0.38), pre-frail (score ≥0.38 and ≤0.82) and frail (score >0.82). Higher FAM scores represented higher levels of frailty. The reported AUC for the composite adverse health outcome was 0.74.
Ethical approval
This study was approved by the Centralised Institutional Review Board in Singapore. Informed consent was obtained from participants who agreed to participate.
Data analysis
Data were entered into and analysed using SPSS version 25.0 (SPSS Inc., Chicago, IL, USA). Descriptive statistics were calculated to report the sociodemographic, clinical data of the patients and time of administration for the tools. The intraclass correlation coefficients (ICCs) were obtained for determination of the interrater reliability of the two screening tools. The construct validity was established by exploring the correlation between the scores of the FAM and the Frail-PPS. A Pearson product-moment correlation coefficient was computed to examine the relationship. Feasibility in terms of efficiency was measured using time needed to administer each screening measure. The construct validity was established by exploring the correlation between the scores of the FAM and the Frail-PPS. A Pearson product-moment correlation coefficient was computed to examine the relationship.
Results
Socio-demographics of patients (n = 62).
Reliability of screening tools - intraclass Correlation coefficients for scores of Frail-PPS and FAM (n = 62).
*Significant value p < .05.
aTaken within 1-h interval.
Interrater reliability of frail-PPS and FAM
Time taken to use the frailty screening tools (n = 62).
Construct validity of frail-PPS and FAM
Correlations between the Frail-PPS and FAM scores were evaluated and showed a significant positive correlation between the two tools at measurement 1 (r = 0.97, p < .001) and measurement 2 (r = 0.97, p < .001), reflecting satisfactory construct validity of the tools (Figure 1). Correlation between Frail-Physical, Psychological and Social (Frail-PPS) and Frailty assessment measure (FAM) measurement time point 1 and 2.
Feasibility
The administration time of Frail-PPS averaged 6.7 min (range = 4.7 to 15 min; SD = 1.7 min). Its median administration time was 6.3 min, with the 25% and 75% percentiles being 5.4 and 7.5 min, respectively. The administration time of FAM averaged 3.3 min (range = 1.3 to 6.0 min; SD = 1.0 min). Its median administration time was as 3.2 min, and the 25% and 75% percentiles were 2.7 and 3.8 min, respectively.
Discussion
A valid frailty screening tool needs to be reliable and feasible to identify patients who are in the high-risk category of functional decline who require further assessment. At the same time, the ideal frailty screening tool needs to be able minimise health care professional and patient burden during its implementation. 9 This study focused on ascertaining the reliability and feasibility of two frailty screening tools-Frail PPS and FAM in the acutely ill hospitalised population. Both the Frail-PPS and FAM were used to screen for frailty among the hospitalised older adults with 31-items and 14-items respectively. The current study showed high interrater reliability scores for both the Frail-PPS and FAM measurement (ICC = 0.95), reflecting a high degree of rater agreement between the two measurements. At the same time, the construct validity was also established by the significant and high positive correlation between the Frail-PPS and FAM measurement (r = 0.97). However, FAM had a shorter administration time, given lesser items in the screening tool. The short administration time indicated that the FAM may be a more feasible screening tool. One challenge identified in the process of implementing and adopting frailty screening in the acute care context is selecting an appropriate frailty screening tool which is reliable and quick to administer. It is essential for a tool to be implemented in the clinical context without taking too much time to complete and can be carried out easily by different healthcare professionals who are caring for the patients. 10
Most studies of the current available screening tools do not report on the tools’ feasibility and user-friendliness. 9 Implementing reliable and feasible screening tools in the inpatient ward setting can aid nurses in their clinical decision making in the planning of care for the older adults during their initial admission or change of condition. Screening for frailty may be the first step in the complex care process for the older patients. Feasibility of the screening tools is a key factor in ensuring the adoption rate of frailty screening. A highly feasible tool requires a short administration time, minimum health care professional training required to administer the tool, as well as simple instructions in the use of the tool. 21
Limitations
Agreement among the experienced ward nurses was high for both the Frail-PPS (ICC = 0.95, 95% CI [0.91, 0.97]) and FAM (ICC = 0.95, 95% CI [0.92, 0.97]). However, these data should be interpreted with caution, as the 62 hospitalised older adults were assessed only by inpatient ward nurses. Advanced nurse practitioners who were specialised in geriatric care were not involved in the study, as they were usually not involved in the routine admission process. The ward nurses in this study received only general instruction regarding the completion of the initial nursing admission assessment using the Frail-PPS and FAM. The high interrater reliability scores agreement scores may indicate that the inpatient ward nurses do not require intensive training to implement the frailty screening tools.
Older adults with dementia or cognitive impairment were not included in this study as frailty status may be affected by these complex medical conditions. However, this may potentially result in a skewed population of frail populations, which should be taken into consideration in future investigations. In addition, patients with length of stay shorter than 48 h were excluded. This may limit the application of the findings to older adults admitted in the emergency department or the short stay unit.
Implications
Both the Frail-PPS and FAM can be considered reliable tools for the screening of frailty among hospitalised older adults. With a shorter administration time, the FAM can be incorporated in the initial nursing admission assessment and utilised on daily basis, highlighting less administrative burden for the nurses. The close rater agreement and correlation between the two tools also argues for choosing the shorter instrument. The inpatient ward nurses do not require extensive instructions regarding the completion of the initial nursing admission assessment using the Frail-PPS and FAM, which indicate the need for a less extensive protocol which is easier to be integrated in the clinical setting. The current study focused on the reliability and feasibility of the both the Frail-PPS and FAM. Future studies may need to further explore other aspects of validity of the screening tools. A qualitative approach can be undertaken to explore nurses’ and hospitalised older adults’ experiences using the frailty screening tools in local context could be explored in future studies. Future studies can also be further conducted to correlate both the Frail-PPS and FAM score with other frailty performance measures.
Conclusion
The findings of this study supported FAM as a reliable and feasible screening tool for frailty among hospitalized older adults. Nurses in the inpatient ward would be able to utilise this short screening tool during their nursing admission assessment to identify those with risk for frailty and referring them for further interventions.
Footnotes
Acknowledgements
We would like to acknowledge all staffs from the inpatient wards in Singapore General Hospital for their support in this study.
Author contributions
Eight authors contributed to the completion of this manuscript. Lim Siew Hoon: Conceptualisation, Methodology, Data collection and review, Writing-original draft preparation, reviewing and editing. Truls Østbye, Rahul Malhotra, Ang Shin Yuh and Fazila Aloweni: Conceptualisation, Methodology, Writing-Reviewing and Editing. Ng Xin Ping, Nurliyana Agus and Raden Nurheryany Binte Sunai: Data collection and data review.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the SingHealth Duke National University of Singapore, Academic Medicine Research Grant, 2019 (AM/HSR004/2018).
