The comprehensive frailty assessment instrument: Development, validity and reliability

Abstract

Population aging forces governments to change their policy on elderly care. Older people, even if they are frail and disabled, are motivated to stay in their own homes and environment for as long as possible. Consequently, the early detection of frail older persons is appropriate to avoid adverse outcomes. Several instruments to detect frailty exist, but none use environmental indicators. This study addresses the development and psychometric properties of the Comprehensive Frailty Assessment Instrument (CFAI). This new self-reporting instrument includes physical, psychological, social and environmental domains. The CFAI showed good fit indices and a high reliability. The underlying structure of the CFAI demonstrates the multidisciplinary nature of frailty. Using the CFAI can stimulate nurses and other community healthcare providers toward a more holistic approach of frailty and can guide them to take appropriate interventions to prevent adverse outcomes such as disabilities or hospitalization.

Introduction

Population aging, a phenomenon in which the distribution of a country's population shifts toward older ages, is affecting all Western societies.¹ To cope with the challenges of a rapidly aging population, several governments have substantially changed their policies on elderly care. Older people, even if they are frail and disabled, are motivated to stay in their own homes and environment for as long as possible. As a consequence, the early detection of frail community-dwelling older persons becomes a significant issue. Several instruments for detection exist, but most have a biomedical emphasis. In most cases, frail older people are detected in clinical settings by screening biomedical indicators (e.g., Fried et al²). However, some efforts have been made to broaden the concept by adding psychological³ and social indicators⁴ or by using these detection instruments in other settings.⁵ Indeed, screening all community-dwelling older persons clinically for frailty will be impossible, particularly for organizational and financial consequences. Moreover, by placing the most emphasis on biomedical indicators, the multidimensional character of frailty is disregarded. According to Gobbens et al,⁵ an overly narrow definition of frailty, focusing exclusively on physical problems in older people, can lead to the fragmentation of care, thereby jeopardizing the attention for the whole person. Problems such as poor-quality housing,⁶ deprived environments and changing social networks⁷ are neglected. Indeed, while aging, older people will depend highly on the sustainability of their own housing conditions, their environment and their network.⁸ If problems arise within these, older people can also become frail.

Against this background, this article aims to broaden the body of knowledge regarding the concept of frailty by introducing a multidimensional, self-administrated instrument capturing 4 domains of frailty: physical, psychological, social and environmental. To the best of our knowledge, this study is the first to include the environmental domain in the assessment of frailty.

As mentioned above, most frailty assessments are dominated by biomedical indicators. Clinicians, for example, use and evaluate a wide range of physical problems. This article aims to provide a correction to what has been termed the biomedical domination⁹ by using a multidimensional approach to measure the concept of frailty. This approach is supported by studies showing that when older women are asked how they perceive frailty, most of their answers are linked not only to physical descriptions (e.g., being small, skinny, rather immobile) but also to contextual, social and emotional problems. This observation suggests that older people themselves may have other impressions about frailty than clinicians.¹⁰ Some scholars therefore include psychological¹¹ and social indicators¹² in addition to the biomedical indicators to measure the concept. Others consider frailty from a live course perspective. Gobbens'¹² model of frailty, for example, expresses relationships between life-course determinants, diseases, frailty and adverse outcomes. Based on this model, the Tilburg Frailty Indicator⁵ was developed, which is an instrument for measuring frailty in community-dwelling older persons in three domains—physical, psychological and social.

The model of Gobbens was used as the basis for the development of the Comprehensive Frailty Assessment Instrument (CFAI), which will be further elaborated in this paper. To meet Markle-Reid's and Browne's¹³ guidelines regarding multidimensionality in frailty, Gobbens' model (see Fig. 1), which was based on a model of Bergman, was used and adapted by introducing the environmental domain of frailty in addition to the physical, psychological and social domains. To the best of our knowledge, the environment in which an older individual lives has never been assessed in frailty research. Schröder-Butterfill,⁶ however, indicates that older people can be confronted with environmental challenges, such as poor-quality housing. Moreover, as older people spend more time at home and in the vicinity of their homes, they will become highly dependent on the sustainability of their own housing conditions and on the spatial context therein.⁸ The relationship of an aging individual with this spatial context is assumed to be essential and to contribute to an aging individual's quality of life.¹⁴ Similarly, Wahl et al¹⁵ argue that the maintenance of independence in the activities of daily life (ADL) and well-being-related outcomes in later life are also related to the utilization and optimization of environmental resources. Evidence also suggests that the proximity of amenities and services may promote health either directly or indirectly through the possibilities they provide for people to live healthy lives.¹⁶

In addition to the inclusion of the environmental domain, five other restrictions and requirements were taken into account in the development of the CFAI. First, the new instrument should not be age related as that would suggest a negative and stereotypical view of aging.⁶ Therefore, age was not included as an indicator of frailty but was viewed as a life-course determinant (see Fig. 1). Second, the lived experiences⁹ of older persons themselves were included. Older people were invited to give their judgment about the physical, psychological, social and environmental domains of frailty. Meeting these requirements and expanding the model beyond biomedical variables will withstand Robertson's remarks regarding the medicalization and gerontologization of old age, where aging is reconceptualized as a new ‘medical space’.¹⁷ Third, as the new self-reporting instrument focuses on frailty in older persons, the instrument must be user friendly, not too long and not complicated. Fourth, the time and effort needed to complete the task must be limited. Finally, the accessibility and usability of the instrument should also be a priority, in particular with regards to font size, layout, language and time taken to complete the survey.