Use of a questionnaire to screen for frailty in the elderly: An exploratory study

34 Aging Clin Exp Res, Vol. 16, No. 1

ABSTRACT. Background and aims: In a pilot studyof community-dwelling geriatric clinic patients (N=48,aged 63-90) we examined the use of a questionnaireto classify frailty status by comparing it with stan-dardized markers of frailty. The questionnaire, de-veloped by Strawbridge et al. in 1998, defines frailtyas difficulty in more than one of four domains offunctioning: physical, cognitive, sensory, and nutri-tive. Methods: Subjects were classified as frail or notfrail by questionnaire and assignment was comparedwith testing of physical and cognitive measures incross-sectional analysis. Demographic variables, func-tional inventories, physical activity levels, clinician im-pression of frailty, and 3-year health outcomes werealso examined. Results: Thirty-three percent of sub-jects were classified as frail. Frailty classification bythe Strawbridge questionnaire was correlated toTimed Up and Go and repetitive Sit-to-Stand tests, bi-manual dexterity and cognitive tests. A discrepancywas found between assignment of cognitive difficul-ty, by questionnaire and cognitive performance.When overall Strawbridge frailty scores were modifiedto account for those with poor cognitive performancewho did not report cognitive difficulty, the prevalenceof frailty increased to 42%. At 3-year follow-up, themodified Strawbridge frailty classification (p<0.05)and clinician impression of frailty (p<0.01) wereboth significant predictors of death and institution-alization combined. Conclusions: This study servesas an initial inquiry into the potential validity and util-ity of the Strawbridge frailty questionnaire as a sim-ple screening tool to identify patients who may war-rant detailed functional testing. (Aging Clin Exp Res 2004; 16: 34-40)©2004, Editrice Kurtis

INTRODUCTIONThe primary goal of assessing frailty status is to rec-

ognize early functional limitations and pre-disabilitiesamenable to interventions, to slow down frailty-related de-cline (1-3). Comprehensive efforts are currently beingundertaken to develop evidence-based guidelines for clin-icians to detect this syndrome and delay its progression assummarized in a recent review (4). One major goal offrailty research is to develop screening tools to identify frailpatients appropriate for early intervention. Althoughfrailty is clinically recognizable as the inability to remainfunctionally stable after stressors such as an acute illness(5-8), no “gold standard” method exists to identify patientsat risk prior to such destabilizing events (9, 10). This is de-spite physiologic characterization of the frailty syndrome(11, 12), identification of risk factors (13) and performancemeasures to identify clinical signs of frailty (14).

Strawbridge et al. (15) conceptualized a working defi-nition of frailty based on the frailty model proposed byBuchner and Wagner (11) and used it to classify currentfrailty status in an elderly, 30-year cohort from theAlameda County study, a longitudinal study of healthand mortality. Frailty was defined as difficulty in more thanone primary domain of functioning (physical, nutritive,cognitive, sensory) using a 16-item questionnaire. Subjectsclassified as frail at 30-year follow-up were found tohave multiple prospective predictors or “antecedents”of frailty status, including heavy drinking, cigarette smok-ing, physical inactivity, depression, social isolation, fair orpoor perceived health, and prevalence of chronic symp-toms and conditions. Frailty status was, in cross-section,associated with reduced activities, poor mental healthand lower life satisfaction. These findings were consideredconsistent with other frailty studies (6, 13).

We hypothesized that the Strawbridge frailty ques-

Aging Clinical and Experimental Research

Use of a questionnaire to screen for frailty in theelderly: An exploratory studyMargaret Matthews1, Amy Lucas1, Rebecca Boland1, Victor Hirth1, Germaine Odenheimer2, DarrylWieland1, Harriet Williams3, and G. Paul Eleazer1

1University of South Carolina School of Medicine/Division of Geriatrics and Palmetto Health Alliance,Columbia, SC, 2University of Oklahoma School of Medicine, Donald W. Reynolds Department of GeriatricMedicine, Oklahoma City, OK, 3University of South Carolina School of Public Health, Department ofExercise Science, Columbia, SC, USA

Key words: Frailty, function, homeostasis, predictors of health outcome, Strawbridge questionnaire.Correspondence: M. Matthews, MD, PhD, Division of Geriatrics, University of South Carolina School of Medicine, Palmetto Health Alliance, Medical Park 9, Suite 630, Columbia, South Carolina 29203, USA.E-mail: [email protected] January 11, 2002; accepted in revised form July 2, 2003.

Questionnaire to screen for frailty in the elderly

Aging Clin Exp Res, Vol. 16, No. 1 35

tionnaire, when used as a working definition of frailty thatincludes multiple domains of function, may be useful as aninitial screening tool to identify frail patients who warrantextensive functional testing. Without a gold standardmeasure of frailty available, we examined the ability of thefrailty questionnaire definition of difficulty in functional do-mains to correlate with performance measures. We com-pared the Strawbridge frailty classification with clinical im-pression of frailty assigned to each subject by their primarycare geriatrician, and examined outcomes of institution-alization and death at 3-year follow-up to test this methodas a predictor of decline.

METHODSA convenience sample of 48 outpatients (aged 63-90)

from a geriatric practice were recruited to complete sev-eral questionnaires and participate in a single 30-minutetesting session including brief measures of physical andcognitive function. Data collection occurred during thesummer of 1999. Exclusion criteria included inability toambulate, medical contraindication to exercise, inability togive informed consent without proxy, and institutional-ization at a nursing home.

Three questionnaires were mailed to subjects to becompleted prior to testing and included: 1) a survey ofdemographic information including activities of dailyliving (ADLs) and instrumental activities of daily living(IADLs) (16); 2) a survey of physical activity; and 3)the Strawbridge frailty questionnaire (see Appendix).The physical activity questionnaire contained questionsabout falls, exhaustion, current activity level, time perweek spent in light, moderate, and vigorous activities,and level of physical activity involvement during eachdecade of life from childhood to present (scored as in-active, moderately active, very active).

The Strawbridge frailty questionnaire consists of 16questions assessing four functional domains: physical,nutritive, cognitive, and sensory. Each domain of thequestionnaire was scored positive when frequent difficultyon a question was reported. A patient was classified asfrail if he/she reported difficulty in more than one domain.Assisted completion of questionnaires was provided forthose patients who preferred assistance and for those withpoor vision or a history of cognitive impairment at the be-ginning of the single testing session.

Performance testing was done in a single 30-minutesession and included two items of cognitive testing andfive items of physical testing. Test of immediate and 3-minute delayed recall portion of the Folstein Mini-Men-tal State Examination (17) and clock drawing test (18)were used to assess cognitive performance. A subjectwas classified as cognitively impaired by a score of lessthan 2 on the 3-minute short-term recall test, or ascore of less than 5 on a 7-point scale for clock drawing.A “modified” Strawbridge frailty score was devised by

substituting this cognitive performance score for thecognitive domain score on the questionnaire, to deter-mine an overall frailty score.

Subjects underwent five physical performance tasks(Timed Up and Go, repetitive Sit-to-Stand, manualgrip strength, modified Tinetti balance test, pegboardtest) to assess lower extremity strength, endurance,upper extremity strength, balance, and manual dex-terity. For the Timed Up and Go test, subjects were in-structed to stand up from a seated position and walk 3meters up and back (3 trials) (19). A timed repetitive Sit-to-Stand test required subjects to rise from a seated po-sition to full height, and then sit again for 10 repetitions(2 trials done, maximum score taken) (20). A modifiedTinetti balance test asked subjects to hold a tandem bal-ance position for 30 seconds (2 trials). If they were un-able to hold the position for at least 5 seconds, semi-tandem position was assessed (21). Hand grip strengthwas measured using a Jamar hand-held dynamometer;patients were asked to squeeze the device maximallywith their dominant hand (2 trials) (22). A test of bi-manual dexterity was used in which patients picked up,turned over, and replaced twelve discs on a pegboardusing both hands (2 trials) (23). Each timed test wasrecorded to the nearest 0.1 second and the mean for alltrials was calculated.

Height and weight were measured, and body mass in-dex (BMI) was calculated. Patients were also askedabout weight change of 5 or more pounds in the pre-ceding 6 months and about appetite loss. Change inweight over the previous 6 months was determinedfor subjects when available from chart review. Medicalcharts were also reviewed for medical diagnoses in-cluding sensory impairments and chronic conditions, de-mographic and health maintenance data, and medica-tions. Strawbridge domain scores were compared withresults from cognitive measures (with Domain III), phys-ical performance and balance (with Domain I), docu-mented weight loss (with Domain II), and presence of asensory impairment (with Domain IV).

Primary care physicians in the geriatric practice wereasked to give a clinical impression of the frailty status oftheir participating patients as “frail” or “non-frail” at thebeginning and close of the 8-week study. Physicianswere not given criteria for these judgments, nor were theysupplied with the Strawbridge questionnaire or other ob-jective test results. Test-retest reliability of physician’sjudgment of frailty status was calculated at the conclusionof the study period (8 weeks). Frailty results from clinicianjudgment were compared with the Strawbridge frailtyscore and the “modified” Strawbridge frailty score. Achart review was performed to determine major out-comes, including death and institutionalization in a long-term care setting after three years, and how this comparedwith assigned frailty status.

M. Matthews, A. Lucas, R. Boland, et al.


Statistical analysisStatistical analysis was performed using SPSS software.

Agreement between the methods of classifying patients ascognitively impaired was estimated using Cohen’s kappa co-efficients. Kappa coefficients were calculated for binaryvariables; otherwise Pearson’s correlation coefficients werecalculated to assess relationship between variables.

RESULTSSubjects (N=48) were Caucasians ranging in age from

63-90 (mean age 76.2) (Table 1). Sixty percent were fe-

male, 63% were married, and 96% had a high school ed-ucation or beyond. Most reported either fair or goodhealth; 46% reported feeling exhausted or tired during thepast month. ADL impairment was present in 3 individu-als (6%); 38% were independent in all ADL and IADL el-ements. The most common medical diagnosis was hy-pertension. By chart review, cognitive impairment wasidentified in 29%, hearing impairment in 21%, and visualimpairment in 38% of subjects.

Table 2 shows that the overall results of the Straw-bridge questionnaire identified 16/48 (33%) as frail. By

Table 1 - Patient characteristics and their association with frailty.

% Frail % Frail % Frail % Distribution (N) Strawbridge Modified Clinician

(N=48) Questionnaire Strawbridge Questionnaire Judgment

Age60-69 13 (6) 17 17** 0*70-79 58 (28) 29 29** 43*80-90 29 (14) 50 79** 57*

Female 60 (29) 31 38 41Marital status

Married 58 (28) 36 39 36Divorced/Separated 6 (3) 0 0 0Widowed 33 (16) 31 50 56Single/Never married 2 (1) 100 100 100

Education< High school 4 (2) 0 0 0High school graduate 38 (18) 28 33 39Some college 25 (12) 25 33 58College graduate 17 (8) 50 75 38> College 17 (8) 50 50 38

Self-reported healthPoor 6 (3) 67 100* 67*Fair 35 (17) 41 47* 65*Good 50 (24) 29 38* 29*Very good 6 (3) 0 0* 0*

Dependency in ADLs/IADLsDressing ADL 6 (3) 67 67 100Bathing ADL 4 (2) 50 50 100Medication IADL 15 (7) 29 71 71Cooking IADL 21 (10) 40 80** 60Finance IADL 27 (13) 39 69* 69*Laundry IADL 17 (8) 50 88** 75Housework IADL 36 (17) 53 77** 71**Shopping IADL 25 (12) 50 83** 75*Driving IADL 27 (13) 46 77** 69*Handyman IADL 52 (25) 40 56* 60*Stairs IADL 8 (4) 50 75 75Transportation IADL 29 (14) 43 71* 64

Mean±SD IADL dependencies 2.56±3.195 3.38±3.304 4.45±3.677** 4.15±3.602**Felt exhausted/tired during past month 46 (22) 46 55 41Diagnoses

Congestive heart failure 6 (3) 33 33 67Hypertension 50 (24) 25 29 42Coronary artery disease 15 (7) 14 29 57Emphysema/COPD 6 (3) 67 67 33Diabetes mellitus 19 (9) 44 56 67Any dementia diagnosis 29 (14) 57* 86** 64Depression 21 (10) 50 60 60Hearing loss/Hearing aid 21 (10) 80** 90** 60Any vision diagnosis 38 (18) 28 44 44

*p<0.05, **p<0.01.

questionnaire, 21% reported significant difficulty in Do-main I (physical function and balance), 4% in Domain II(nutritive function), 29% in Domain III (cognitive function)and 65% in Domain IV (sensory function). Overall, fouradditional subjects were identified as frail, when subjectswithout self-report of cognitive difficulty were reanalyzedbased on their cognitive performance. By combiningboth approaches, the total number of frail subjects in-creased to 42% (20/48). IADLs were significantly cor-related with frailty status, both individually and by meanscores using the modified Strawbridge analysis (r= 4.45+/-3.677) but not the strict Strawbridge classification.

Correlations between the Strawbridge frailty scoreand performance on 5 functional measures are shown inTable 3. Performance on the repetitive Sit-to-Stand wassignificantly related to frailty status (r=0.499, p=0.001).Bimanual dexterity (r=0.343; p=0.017) and Timed Upand Go (r=0.321; p=0.026) performances were alsosignificantly correlated with frailty status. Neither tan-dem balance scores or grip strength were related toStrawbridge frailty scores.

We examined the relationship between self-report dif-ficulty in Domain I (physical function and balance) of

the Strawbridge questionnaire and actual performance onmeasures of balance, endurance, and upper and lowerbody strength. Correlations between Domain I questionsand performance measures are given in Table 4. Subjectsmost likely to report a sudden loss of balance had poor-er performances on Timed Up and Go, repetitive Sit-to-Stand, and grip strength tests. The correlation betweenperformance on tandem balance and self-report of balancedifficulty was modest (r=0.458; p=0.058). Arm weaknesswas correlated with poor grip strength (r=–0.381;p=0.008) and bimanual dexterity (r=0.415; p=0.003); italso was significantly related to poor performance onthe repetitive Sit-to-Stand test (r=0.451; p=0.001). Re-port of leg weakness was significantly correlated withpoorer performance on the repetitive Sit-to-Stand(r=0.343; p=0.017) and grip strength (r=–0.295;p=0.042), but not with the Timed Up and Go test(r=0.255; p=0.08). The report of dizziness on risingwas not significantly related to performance on any of themeasures.

We compared responses to questions on StrawbridgeDomain II (nutritive) to documented weight change fromchart review. The relationship between report of weight

Table 2 - Association of frailty with death and institutionalization1 (N=48).

Frailty measure No. of frail subjects 3-year outcome: Odds Ratio (95% CI)death or institutionalization

Strawbridge Questionnaire 16 (33%) 40% 2.286 (0.603-8.665)I. Physical Function Domain 10 (21%) 44% 2.489 (0.548-11.313)II. Nutritive Function Domain 2 (4%) 50% 2.667 (0.154-46.105)III. Cognitive Function Domain 14 (29%) 36% 1.667 (0.430-6.460)IV. Sensory Function Domain 31 (65%) 33% 2.167 (0.500-9.395)

Modified Strawbridge Questionnaire 20 (42%) 47% 5.175 (1.286-20.824)Clinician judgment of frailty 20 (42%) 55% 14.667 (2.706-79.503)

113 subjects were institutionalized or died during follow-up; 2 subjects were lost to follow-up.

Table 3 - Correlation matrix of performance measures and frailty (p-value).

Frailty Score1 Mean Timed Mean Tandem Mean Sit-to- Mean Grip Mean Bimanual Up and Go Balance Stand Time Strength Dexterity

Frailty Score – 0.321 -0.118 0.499 -0.246 0.343(0.026) (0.426) (<0.001) (0.091) (0.017)

Mean Timed Up and Go – -0.365 0.366 -0.398 0.455(0.011) (0.011) (0.005) (0.001)

Mean Tandem Balance – -0.071 0.437 -0.587(0.634) (0.002) (0.000)

Mean Sit-to-Stand Time – -0.404 0.342(0.004) (0.018)

Mean Grip Strength – -0.183(0.212)

Mean Bimanual Dexterity –

1Frailty score: 0= “not frail”; 1= “frail”.





loss and documented weight loss was strong (r=0.703).Difficulty with vision and hearing (Domain IV) was themost frequently reported impairment. The relationship be-tween a clinical diagnosis of hearing impairment takenfrom chart review and report of difficulty was significant(r=0.380; p=0.008). There was no significant relationshipbetween previous diagnosis of visual impairment anddifficulty on vision-related questions.

Clinicians (all geriatricians) whose patients participatedin this study were asked to designate the frailty status ofpatients prior to and after the 8-week study period. The8-week test-retest agreement of physician frailty judg-ments was 94%. Forty-two percent of patients were es-timated as frail by physician assessment (Table 2). Agree-ment between physician frailty assessment and Straw-bridge classification was modest at 67% (kappa=0.294).When compared with the “modified” Strawbridge frailtyscore, correcting for cognitive impairment, agreement im-proved, but only slightly, to 71% (kappa= 0.400).

Results for 3-year follow-up analysis were obtained bychart review and are summarized in Table 2. Of 48 sub-jects, information about outcomes of death and institu-tionalization were available for 46 of 48 subjects. The“modified” Strawbridge frailty score (coeff. 5.18; p<0.05)but not the Strawbridge frailty score (coeff. 2.28) was asignificant predictor of institutionalization and death com-bined. Frailty in any single Strawbridge domain (physical,cognitive, sensory, nutritive) was not predictive of theseoutcomes. The association between mean dependentIADLs and adverse outcomes of death and institutional-ization showed an OR of 2.778 (1.485-5.198). Clinicianimpression of frailty was most strongly predictive of neg-ative health outcome (coeff. 9.9; p<0.01).

DISCUSSIONIn a small pilot study of elderly patients from a geriatric-

only primary care practice, multiple functional measureswere measured and compared with a qualitative standard

of frailty defined by Strawbridge et al. (15) as impairmentin more than one domain of functioning: physical, nutri-tive, cognitive, and sensory. The purpose of the pre-sent study was to serve as an initial exploration of theStrawbridge frailty questionnaire as a brief screening toolfor frailty. Although the study was conducted, for con-venience, using subjects from a primary-care geriatricclinic, such a tool would be more useful to identify thosewith pre-disability who could benefit from appropriate geri-atric services.

Our findings show that frailty status as determinedby the Strawbridge questionnaire is consistent with ex-pected findings on many single-item measures of func-tional ability. This includes performance on the Timed Upand Go test, repetitive Sit-to-Stand test, bimanual dex-terity, and cognitive tests (Table 3). This observation isconsistent with reported findings in which measures ofstrength, dexterity, endurance and cognition are significantindependent predictors of impending overall functional dis-ability (24-26).

We established that self-report of difficulty in the phys-ical domain (Table 3), but not the cognitive domain, relatesto objective results from functional testing. As expected,reported difficulty correlated with measured performancein several related areas such as arm weakness with gripstrength, and leg weakness with performance on therepetitive Sit-to-Stand maneuver, and has been examinedin many other studies (27-29). Additionally, correlationswere found between apparently unrelated areas such asdifficulty with arm weakness and poor balance with per-formance on the repetitive Sit-to-Stand maneuver, possiblyrelated in general to overall weakness. These correla-tions, however, may be weaker than expected due to self-report bias, further exacerbated by inclusion of somecognitively impaired subjects (30, 31).

Performance measures have long been thought tohave significant advantages over self-report (32, 33).Cognitive ability is known to be a significant contributor

Table 4 - Correlations of performance measures and physical function domain (p-value).

Mean Timed Mean Tandem Mean Sit-to- Mean Grip Mean Bimanual Up and Go Balance Stand Time Strength Dexterity

Experienced sudden loss 0.458 -0.275 0.422 -0.450 0.227of balance1 (0.001) (0.058) (0.003) (0.001) (0.121)Have arm weakness1 0.231 -0.140 0.451 -0.381 0.415

(0.114) (0.341) (0.001) (0.008) (0.003)Have leg weakness1 0.255 0.049 0.343 -0.295 0.041

(0.080) (0.739) (0.017) (0.042) (0.781)Get dizzy when rising from 0.133 0.096 0.174 -0.070 0.104a seated position1 (0.368) (0.516) (0.237) (0.637) (0.481)Overall Domain 1 Score2 0.387 -0.087 0.501 -0.304 0.437

(0.007) (0.558) (<0.001) (0.036) (0.002)

1Scores for Physical Function and Balance Domain questions: 1= Rarely/Never; 2= Sometimes; 3= Often; 4= Very Often. 2Overall Domain 1 Score: 0= No Problem; 1= Problem.

to baseline vulnerability (8) and this probably occurs evenat a stage of early cognitive difficulty (34, 35). We at-tempted to reduce some of this bias by modifying theStrawbridge score to reflect those with objective cognitivefrailty not identified by the questionnaire, while still al-lowing examination of a multi-domain model of frailty. Weacknowledge that correcting for self-report bias to somedegree compromises the very idea that a simple screen-ing tool may be used to identify those with a complex syn-drome. Any screening method for frailty needs to besensitive to cognitive impairment and this presents a sig-nificant obstacle for future research.

Frailty status as measured by the modified Straw-bridge score did correlate with adverse 3-year healthoutcome (Table 2) and is consistent with the idea thatfrailty is a precursor to premature disablement and death(2, 3). This was not seen for the Strawbridge question-naire, prior to adjusting for objective cognitive impairment,nor was it seen for any one functional domain, physical,nutritive, sensory, or cognitive. Although the Strawbridgequestionnaire result is comparable to the standardized KatzIADL questionnaire with regard to assessing risk of 3-yearadverse outcome, the modified Strawbridge score is su-perior. This implies, as discussed above, that correction forself-report bias based on cognitive difficulty greatly im-proves such a tool and will be an important obstacle to de-velopment of a screening tool.

Clinical impression of frailty status when assessed byeach subjects’ primary care geriatrician was a more pow-erful predictor of adverse health outcome than the Straw-bridge questionnaire. This is not surprising, since geria-tricians focus on functional assessment and interventionsto delay disability in caring for elderly patients with chron-ic disease. It may be that the Strawbridge questionnaireoveremphasizes the impact of the sensory domain: aperception that clinicians may not regard as a significantrisk for morbid decline. Although geriatrician assessmentof frailty cannot be considered a gold standard measure-ment, it may be a reasonable surrogate standard whencoupled with a standardized functional battery such as thePhysical Performance Test (36). However, whether or notclinical assessment of frailty by non-geriatricians whocare for most elderly patients would be as powerful a pre-dictor of adverse outcome is unknown.

CONCLUSIONSWe acknowledge multiple limitations in conducting

this pilot study – most notably, the absence of a true goldstandard for frailty by which to measure our outcome. An-other limitation is that the small size of the study pro-hibited multivariate analysis of performance measurecorrelations. This, in addition to the lack of ethnic andeconomic diversity of subjects, and the fact that the studypopulation was selected from a geriatric referral settinglimits the generalizability of our findings. Although the

Strawbridge questionnaire was not intended as a screen-ing tool for frailty, its ability to assess pre-disability dys-function within a conceptual framework is compelling. Ourpilot data implies a level of qualitative validity to supporta larger trial investigation of the Strawbridge questionnaireto screen for frailty.

APPENDIX Strawbridge Questionnaire:1

Domain I: Physical function and balance1. Have you experienced a sudden loss of balance?2. Do you have arm weakness?3. Do you have leg weakness?4. Do you get dizzy when you rise from a seated position?

Domain II: Nutritive function1. Have you experienced unexplained weight loss?2. Have you experienced a loss of appetite?

Domain III: Cognitive function1. Do you have difficulty finding the right word when you are

speaking?2. Do you have difficulty paying attention?3. Do you have difficulty remembering things?4. Do you often forget where you put things?

Domain IV: Sensory function1. Do you have difficulty reading a newspaper?2. Do you have difficulty recognizing a friend from across the

street?3. Do you have difficulty reading signs at night?4. Do you have difficulty hearing on the phone?5. Do you have difficulty carrying on a conversation in a noisy room?6. Do you have difficulty hearing a normal conversation?

Scores on domains I, II, and III were 1 (rarely or never had the prob-lem in the last 12 months), 2 (sometimes had the problem), 3 (often hadthe problem), and 4 (very often had the problem). Scores on sensorydomain IV were 1 (have no difficulty), 2 (have a little difficulty), 3 (havesome difficulty), and 4 (have a great deal of difficulty). Subjects scoring3 or higher on at least one item on any domain were considered to bepositive for frailty in that domain. Patients were scored as ‘frail’ over-all when they scored as positive in more than one domain.

1 From Strawbridge WJ, Shema SJ, Balfour JL, Higby HR, KaplanGA. Antecedents of frailty over three decades in an older cohort. JGerontol 1998; 53B: S9-16.

REFERENCES1. Wolfe SL, Kutner NG, Green RC, McNeely E. The Atlanta FIC-

SIT Study: two exercise interventions to reduce frailty in elders. JAm Geriatr Soc 1993; 41: 329-32.

2. Province MA, Hadley EC, Hambrock MC, et al. The effects of ex-ercise on falls in elderly patients: a preplanned meta-analysis of theFICSIT trials. JAMA 1995; 273: 1341-7.

3. Rubenstein L, Josephson K, Trueblood P, et al. Effects of groupexercise program strength, mobility and falls among fall-prone el-derly men. J Gerontol 2000; 58: M317-21.

4. Hogan DB, MacKnight C, Bergman H, on behalf of the Steer-ing Committee, Canadian Initiative on Frailty and Aging. Mod-els, definitions, and criteria of frailty. Aging Clin Exp Res2003; 15 (Suppl.): 3-29.

5. Hirsch CH, Sommers L, Olsen A, Mullen L, Winograd CH.The natural history of functional morbidity in hospitalized older pa-tients. J Am Geriatr Soc 1990; 38: 1296-303.





6. Campbell AJ, Buchner DM. Unstable disability and the fluctuationsof frailty. Age Aging 1997; 26: 315-8.

7. Carlson JE, Zocchi KA, Bettencourt DM, et al. Measuring frailtyin the hospitalized elderly: concept of functional homeostasis. AmJ Phys Med Rehabil 1998; 77: 252-7.

8. Rozzini, R. Change in functional status during hospitalization inolder adults: A geriatric concept of frailty. J Am Geriatr Soc 2000;48: 1024-5.

9. Gill, TM, Williams CS, Tinetti ME. The combined effects of base-line vulnerability and acute hospital events on the development offunctional dependence among community-living older persons. JGerontol 1999; 54A: M377-83.

10. Rockwood K, Stadnyk K, MacKnight C., McDowell I, Hebert R,Hogan DB. A brief clinical instrument to classify frailty in elder-ly people. Lancet 1999; 353: 205-6.

11. Buchner DM, Wagner EH. Preventing frail health. Clin GeriatrMed 1992; 8: 1-17.

12. Walston J, Fried LP. Frailty and the older man. Med Clin NorthAm 1999; 83: 1173-94.

13. Fried LP, Guralnik JM. Disability in older adults: evidence re-garding significance, etiology, and risk. J Am Geriatr Soc 1997;45: 92-100.

14. Hirsch CH, Fried LP, Harris T, Fitzpatrick A, Enright P, SchulzR. Correlates of performance-based measures of muscle functionin the elderly: The cardiovascular health study. J Gerontol 1997;52A: M192-200.

15. Strawbridge WJ, Shema SJ, Balfour JL, Higby HR, Kaplan GA.Antecedents of frailty over three decades in an older cohort. JGerontol 1998; 53B: S9-16.

16. Katz S. Assessing self-maintenance: activities of daily living, mo-bility and instrumental activities of daily living. J Am GeriatrSoc 1983; 31: 721-7.

17. Folstein M, Folstein S, McHugh P. Mini-mental state. J PsycholRes 1975; 12: 189-98.

18. Watson Y, Arfken C, Birge S. Clock completion: an objectivescreening test for dementia. J Am Geriatr Soc 1993; 41:1235-40.

19. Posiadlo D, Richardson S. The timed “up and go”: A test of ba-sic functional mobility for frail elderly persons. J Am GeriatrSoc 1991; 39: 142-8.

20. Csuka M, McCarty DJ. Simple method for measurement of low-er extremity muscle strength. Am J Med 1985; 78: 77-8.

21. Bohannon RW, Larkin PA, Cook AC, Gerar J, Singer J. De-crease in timed balance test scores with aging. Phys Ther 1984;64: 1067-70.

22. Bohannon RW. Test-retest reliability of hand held dynamometryduring a single session of strength assessment. Phys Ther 1986;66: 206-9.

23. Frey C. Pegs-over task, The Perceptual-Motor DevelopmentLaboratory Protocols Manual. University of South Carolina Press,Columbia, SC 1997.

24. Frisoni G, Fratiglioni L, Fastbom J, Guo Z, Viitanen M, WinbladB. Mild cognitive impairment in the population and physicalhealth: Data on 1,435 individuals aged 75-95. J Gerontol 1996;55A: M322-8.

25. Rantanen T, Guralnik JM, Izmirlian G, et al. Association ofmuscle strength with maximum walking speed in disabled olderwomen. Am J Phys Med Rehabil 1998; 77: 299-305.

26. Rantanen T, Guralnik JM, Sakari-Rantala R, et al. Disability, phys-ical activity, and muscle strength in older women: the Wom-en’s Health and Aging Study. Arch Phys Med Rehabil 1999; 80:130-5.

27. Guralnik JM, Reuben DB, Buchner DM, Ferrucci L. Perfor-mance measures of physical function in comprehensive geri-atric assessment. In Rubenstein L, Wieland D, Bernabei R, Eds.Geriatric assessment technology: the state of the art. Milano: Kur-tis, 1996: 59-74.

28. Rathouz PJ, Kasper JD, Zeger SL, et al. Short-term consistencyin self-reported physical functioning among elderly women: theWomen’s Health and Aging Study. Am J Epidemiol 1998; 147:764-73.

29. Tinetti ME. Performance-oriented assessment of mobility problemsin elderly patients. J Am Geriatr Soc 1986; 34: 119.

30. Sager MA, Dunham NC, Schwantes A, Mecum L, Halverson K,Harlowe D. Measurement of activities of daily living in hospital-ized elderly: A comparison of self-report and performance-basedmethods. J Am Geriatr Soc 1992; 40: 457-62.

31. Carlson MC, Fried LP, Xue Q, Bandeen-Roche K, Zeger SL,Brandt J. Association between executive attention and physicalfunctional performance in community-dwelling older women. JGerontol 1999; 54B: S262-70.

32. Guralnik JM, Branch LG, Cummings SR, Curb JD. Physicalperformance measures in aging research. J Gerontol 1989; 44:M141-6.

33. Simonsick EM, Guralnik JM, Fried LP. Who walks? Factors as-sociated with walking behavior in disabled older women with andwithout self-reported walking difficulty. J Am Geriatr Soc 1999;47: 672-80.

34. Gill T, Williams C, Tinetti M. Assessing risk for the onset of func-tional dependence among older adults: the role of physical per-formance. J Am Geriatr Soc 1995; 43: 603-9.

35. Albert S, Michaels K, Padilla M, et al. Functional significance ofmild cognitive impairment in elderly patients without a dementiadiagnosis. Am J Geriatr Psychol 1999; 7: 213-20.

36. Brown M, Sinacore D, Binder E, Kohrt W. Physical and perfor-mance measures for the identification of mild to moderate frailty.J Gerontol 2000; 55A: M350-5.

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Use of a questionnaire to screen for frailty in the elderly: An exploratory study