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RAPID COMMUNICATION |
1 Departments of Internal Medicine and Geriatrics, University Hospital Groningen, the Netherlands.
2 Interuniversity Center for Social Science, Theory and Methodology (ICS), University of Groningen, the Netherlands.
3 Department of Social Psychology, University of Groningen, the Netherlands.
Address correspondence to Hanneke Schuurmans, University Hospital Groningen, Departments of Internal Medicine and Geriatrics, P.O. Box 30 001, 9700 RB Groningen, the Netherlands. E-mail: schuurmans{at}dds.nl
Abstract
Background. Selecting elderly persons who need geriatric interventions and making accurate treatment decisions are recurring challenges in geriatrics. Chronological age, although often used, does not seem to be the best selection criterion. Instead, the concept of frailty, which indicates several concurrent losses in resources, can be used.
Methods. The predictive values of chronological age and frailty were investigated in a large community sample of persons aged 65 years and older, randomly drawn from the register of six municipalities in the northern regions of the Netherlands (45% of the original addressees). The participants' generative capacity to sustain well-being (i.e., self-management abilities) was used as the main outcome measure.
Results. When using chronological age instead of frailty, both too many and too few persons were selected. Furthermore, frailty related more strongly (with beta values ranging from –.25 to –.39) to a decline in the participants' self-management abilities than did chronological age (with beta values ranging from –.06 to –.14). Chronological age added very little to the explained variances of all outcomes once frailty was included.
Conclusions. Using frailty as the criterion to select older persons at risk for interventions may be better than selecting persons based only on their chronological age.
However, chronological age may not be the best selection criterion, because it is not the best predictor of adverse processes or outcomes of interventions and treatments (4,6,8–12). Persons who need treatment may be falsely excluded when selections are made based on age, whereas persons who do not need interventions may be inappropriately included. Therefore, a selection criterion is needed that works better than age, a concept that tells us more about the process of aging, which involves losses in different domains of functioning, a higher risk for chronic conditions, a higher risk for death, and so forth. Chronological age is only a proxy for many adverse processes. Frailty, the risk for adverse outcomes due to losses in different domains of functioning, relates directly to these adverse processes. Frailty is a loss of resources in several domains of functioning, which leads to a declining reserve capacity for dealing with stressors. Most medical interventions focus on these lost resources, such as mobility loss or a specific disease, but they focus primarily on single resources. However, elderly persons often experience loss of several resources concurrently; that is, they become frailer in a general sense.
Even individual mortality risk, which can be seen as the ultimate outcome of age and frailty (13), can be better predicted by frailty than by chronological age (14). However, no test of frailty versus chronological age has been conducted with self-management abilities as the main outcome measure. The bundle of losses in resources constituting frailty is expected to lead to the loss of self-management abilities. Self-management abilities are skills needed by an elderly person to prevent the loss of resources, to manage the decline and loss of resources, and to sustain well-being (N. Steverink, S. Lindenberg, and J. P. J. Slaets, unpublished data, May 2003; all unpublished data and items from the measurement scales used are available from the first author). These self-management abilities can be regarded as a person's generative capacity to sustain well-being into old age. Arguably, they are even more important as an outcome measure of interventions than is death, because they may be a more relevant concept for older person's daily lives. The primary aim of this study was to determine whether frailty is a better predictor of adverse outcomes in elderly persons (and thus a better selection criterion for interventions) than age, using these self-management abilities as the main outcome measure.
METHODS
Participants
In August 2001, a questionnaire was sent to a sample of 3000 community-dwelling elderly persons aged 65 years and older, randomly drawn from the registers of six municipalities in the northern regions of the Netherlands. These municipalities consist of smaller and larger areas and the residents have an income comparable to the national mean. A total of 45% of the addressees returned the questionnaire (n = 1338). Many reasons for nonresponse were physical, which may have caused an under-representation of severely frail respondents. The average age was 74.2 years (standard deviation, 6.59 years), and the oldest respondent was 98 years old.
Outcome Measures
Frailty was measured using the Groningen Frailty Indicator (15), a short, easy to administer 15-item screening instrument to determine a person's level of frailty (K–R 20 =.71). The Groningen Frailty Indicator screens for the loss of functions and resources in 4 domains of functioning: physical (mobility functions, multiple health problems, physical fatigue, vision, hearing), cognitive (cognitive functioning), social (emotional isolation), and psychological (depressed mood and feelings of anxiety), and was found to be a one-dimensional concept. The Groningen Frailty Indicator is shown in the Appendix.
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Self-management abilities were measured using the Self-Management Ability Scale-30 (H. Schuurmans, N. Steverink, N. Frieswijk, et al., unpublished data, July 2003), which measures the level of self-management ability (SMA), an index for six self-management abilities together (total 
=.84). These six interdependent self-management abilities are specified in the theory of successful self-management of aging as the core abilities needed to sustain well-being (N. Steverink, S. Lindenberg and J.P.J. Slaets, unpublished data, May 2003). They are (a) multifunctionality of resources (these lead to well-being in several ways simultaneously), (b) variety in resources (such that a person has more than 1 resource to realize well-being), (c) having a positive frame of mind regarding expectations for the future (the person expects to maintain or increase resources, instead of only sustaining further losses), (d) investment behavior (to maintain and achieve possible growth of resources), (e) self-efficacy beliefs (beliefs in one's competence to realize well-being), and (f) taking the initiative. The scale consists of six subscales, one for each SMA. For the overall SMA score, the average of the six subscale scores was taken.
RESULTS
First, we compared respondents selected by their age (75 years and older) and respondents selected by their levels of frailty. A frailty score of 4 or higher can be regarded as moderately frail according to a panel of geriatric experts (15). The group of respondents selected by age was larger than the group selected by frailty, contained many persons with only a low level of frailty, and had a significantly higher level of all self-management abilities, except for multifunctionality (Table 1). The group of respondents selected by frailty, however, also included persons younger than 75 years. This shows that frailty is a more suitable selection criterion than age when self-management abilities are used as the main outcome measure.
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As expected, frailty relates more strongly to a decline in self-management abilities than does chronological age. Therefore, using frailty to select older persons at risk is an improvement compared with selecting persons for interventions based only on their chronological age, because it is likely to yield a more accurate selection. To measure frailty, the Groningen Frailty Indicator is a short and easy-to-use instrument, and it seems a reasonable and manageable alternative for using chronological age as a selection criterion for interventions.
Acknowledgments
Supported by grants from the Netherlands Organization for Scientific Research, The Hague, and the University of Groningen, Groningen, the Netherlands.
None of these funding sources had any role in the collection of data, interpretation of results, or preparation of this article.
Received October 30, 2003
Accepted November 13, 2003
References
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 S. P. van Tongeren, J. P. J. Slaets, H. J. M. Harmsen, and G. W. Welling Fecal Microbiota Composition and Frailty Appl. Envir. Microbiol., October 1, 2005; 71(10): 6438 - 6442. [Abstract] [Full Text] [PDF]
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