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Background: Due to differences in the definition of frailty, many different screening instruments have been developed. However, the predictive validity of these instruments among community-dwelling older people remains uncertain. Objective: To investigate whether combined (i.e. sequential or parallel) use of available frailty instruments improves the predictive power of dependency in (instrumental) activities of daily living ((I)ADL), mortality and hospitalization. Design, setting and participants: A prospective cohort study with two-year follow-up was conducted among pre-frail and frail community-dwelling older people in the Netherlands. Measurements: Four combinations of two highly specific frailty instruments (Frailty Phenotype, Frailty Index) and two highly sensitive instruments (Tilburg Frailty Indicator, Groningen Frailty Indicator) were investigated. We calculated sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for all single instruments as well as for the four combinations, sequential and parallel. Results: 2,420 individuals participated (mean age 76.3 ± 6.6 years, 60.5% female) in our study. Sequential use increased the levels of specificity, as expected, whereas the PPV hardly increased. Parallel use increased the levels of sensitivity, although the NPV hardly increased. Conclusions: Applying two frailty instruments sequential or parallel might not be a solution for achieving better predictions of frailty in community-dwelling older people. Our results show that the combination of different screening instruments does not improve predictive validity. However, as this is one of the first studies to investigate the combined use of screening instruments, we recommend further exploration of other combinations of instruments among other study populations.

Fried’s phenotype frailty criteria include three self-report questions (weight loss, exhaustion and low physical activity) and two performance-based measures (slowness (walk time) and weakness (handgrip strength)). The present study investigates whether the two performance-based criteria could be replaced by self-report questions. A cross-sectional validation study was conducted among 135 community-dwelling older people (65+) with different stages of frailty. Eleven questions related to walk time and ten questions about handgrip strength were selected. Both the self-report questions and performance-based measurements of walk time (time needed to walk 15 feet at own pace) and handgrip strength (maximum handgrip strength using a hand dynamometer) were assessed. Backward logistic regression analyses showed that four questions for walk time and two questions for handgrip strength were optimal. This indicates that it seems possible to replace the two performance-based measures by a small set of self-report questions, which can particularly be helpful in Iarge-scale research.

Although there is a lively ongoing debate on the nature and definition of frailty, researchers agree that the more frail older persons are, the higher their risk of adverse frailty outcomes is. Nevertheless, there are pre-frail and frail people who do not suffer from these adverse outcomes. This suggests that more factors play a role in the occurrence of these outcomes. Research on the potential moderating effect of resources on frailty outcomes among pre-frail and frail persons is, however, scarce. The present prospective cohort study (n=2420) investigates the moderating effects of level of education, income, availability of informal care, living situation, sense of mastery, and self-management abilities on the relation between the level of frailty and the adverse outcomes mortality, hospitalization and (I)ADL disability over a 2-year period. Results show that frail older people have increased odds for mortality and hospitalization, and a higher risk for increased disability compared to pre-frail older people. Only for the development of disability, two resources (income and living situation) had a moderating effect of the impact of frailty. However, overall the included resources had no consistent and convincing moderating effects. The results of the present study indicate (a) that the impact of the level of frailty on adverse outcomes can be generally considered as main effects, and (b) that it is not yet clear whether, and how presumed resources impact the pathway from frailty to adverse outcomes.