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Journal of Interprofessional Care
Frailty scales – their potential in interprofessional working with
older people: a discussion paper
1Please provide department or division name for affiliations 1,2, 4, 5.
Frailty scales – their potential in interprofessional working with older
people: a discussion paper
Leon Poltawski1, Claire Goodman1, Steve Iliffe2, Jill Manthorpe3, Heather Gage4,
Vari Drennan5, & Dhrushita Shah5
1University of Hertfordshire, Hatfield, UK,2University College London, London, UK,3Social Care Workforce Research Unit, Kings
College London, London wc2b 4ll, UK,4University of Surrey, Guildford, Surrey, UK,5Kingston University and St George’s,
University of London, Kingston, UK
New models of interprofessional working are continuously
being proposed to address the burgeoning health and social
care needs of older people with complex and long-term health
conditions. Evaluations of the effectiveness of these models
tend to focus on process measures rather than outcomes for
the older person. This discussion paper argues that the
concept of frailty, and measures based on it, may provide a
more user-centred tool for the evaluation of interprofessional
services – a tool that cuts across unidisciplinary preoccupations
and definitions of effectiveness. Numerous frailty scales have
been developed for case identification and stratification of risk
of adverse outcomes. We suggest that they may also be
particularly suitable for evaluating the effectiveness of
interprofessional working with community-dwelling older
people. Several exemplars of frailty scales that might serve this
purpose are identified, and their potential contributions and
limitations are discussed. Further work is required to establish
which is the most suitable scales for this application. The
development of an appropriate frailty scale could provide an
opportunity for interprofessional debate about the forms of
care and treatment that should be prioritised to improve the
health and well-being of this population.
Keywords: Frailty; measurement; older people; community
care; integrated working; discussion paper
The care of people with long-term and complex conditions
is a key concern for health and social care policy makers
in developed countries across the world (Department of
Health, 2001; Hofmarcher, Oxley, & Rusticelli, 2007). In
England, about 30% of the population are living with such
conditions, and they are estimated to account for 70% of the
total health and social care spent (Department of Health,
2010). In the United States, it is estimated that by 2050, the
number of individuals using paid long-term care services
will likely double from the 13 million using them in 2000
(U.S. Department of Health and Human Services, 2003).
New models of care provision are constantly being trialled
or implemented in an effort to deal more effectively with
this ever-increasing demand (Lloyd & Wait, 2006).
The development of care for older people with complex
needs living in the community is predicated on the
assumption that increasing levels of organisational and
professional collaboration will optimise service delivery for
this group (Department of Health, 2010; Flaherty, 1987;
Kodner, 2006). Interprofessional working, an approach to
person-centred care through close collaboration between
health and social care workers, is an example of this
policy in practice (Hoffman, Rosenfield, Gilbert, &
Oandasan, 2008). However, evaluations of the impact of
such collaborative models of care have been disappointing.
For example, a recent systematic review of controlled trials
of integrated interventions targeting frail older people in
several countries found that many outcomes did not favour
the intervention over the control, and concluded that there
was only limited evidence that co-ordinated and integrated
care is beneficial (Eklund & Wilhelmson, 2009). Many of
the outcome measures used in the trials were unvalidated.
Studies of community partnership working often lack
methodological rigour (El Ansari & Weiss, 2006), and a
greater focus on outcomes for the older person as well as for
service-providers is required. The problem for practitioners,
researchers and those responsible for buying or commis-
sioning services is that little is known about the impact
of different collaborative models on users and patients,
because of difficulties establishing a causal link between a
way of working that involves multiple practitioners and
individual outcomes (Dowling, Powell, & Glendinning,
2004). Whilst it is accepted that new structured approaches
Correspondence: Leon Poltawski, University of Hertfordshire, Hatfield, UK. E-mail: firstname.lastname@example.org
Received 4 October 2010; revised 31 January 2011; accepted 7 February 2011.
CE: LB QA: EP COLL:PG: padmavathym 24/2/11 18:08
Journal of Interprofessional Care, 2011, 00: 1–7
? 2011 Informa UK, Ltd.
ISSN 1356-1820 print/1469-9567 online
are needed that recognise the existence and complexity of
multi-morbidity among older people and encourage inter-
professional working (Boult et al., 2008; Reuben, Roth,
Kamberg, & Wenger, 2003; Smith & O’Dowd, 2007), these
may still exclude important social determinants of health
At present, there appears to be little reference in the
interprofessional literature to user outcomes in the evalua-
tion of care for older people. Much evaluative work focuses
on the education of practitioners (Reeves et al., 2010) or
uses only process measures, such as record keeping and
cross-agency coordination (Tucker et al., 2009). Limited
attention has been given to person-specific outcomes in
evaluations of services for older people (Eloranta, Welch,
Arve, & Routasalo, 2010; Reed, Cook, Childs, & McCor-
mack, 2005; Tucker et al., 2009), and they receive little
consideration in tools developed specifically to assess
interprofessional working. For example, the Integrated
Team Monitoring & Assessment Readiness Tool, provided
by the former English Care Standards Improvement
Partnership (http://www.csip.org.uk) is exclusively pro-
cess-oriented, addressing issues such as team purpose and
working arrangements. The Creating Capable Teams
Approach (Reed et al., 2005), which was commissioned by
the English Department of Health, includes identification of
service user and carer needs as part of the planning process,
but does not specify any user outcomes by which the
effectiveness of organisational changes might be measured.
In fact, discussions of policy and practice in interprofes-
sional care for older people tend to exclude the voices of
older people altogether (Eloranta et al., 2010; Glendinning,
2003). Clearly, there is a need to translate the rhetoric of a
user-focussed service into reality by considering the impact
on the individual’s health and wellbeing as a primary
outcome measure in the evaluation of care for older people.
One way forward is to employ a multidimensional
outcome that can encompass and quantify the complexity
of an individual’s situation, and that addresses both
personal health and social dimensions. The concept of
frailty allows for the use of such a composite measure.
Frailty measures have been proposed as tools for case
finding or treatment planning, but their potential for
monitoring and evaluating interprofessional care remains
relatively unexplored. Used for such purposes, frailty
instruments may be of value to both practitioners and
budget-holders. In this article, we describe some current
issues in the definition and use of frailty measures, and
discuss their potential in the context of interprofessional
working with community-dwelling older people.
This article is not a review of frailty – several have
already been published or are underway (Daniels, van
Rossum, de Witte, & van den Heuvel, 2008; De Lepeleire,
Iliffe, Mann, & Degryse, 2009; Hogan, MacKnight, &
Bergman, 2003; Karunananthan, Wolfson, Bergman, Be-
land, & Hogan, 2009; Markle-Reid & Browne, 2003). Rather
it is intended to encourage debate about the value of the
concept and its measurement in interprofessional working,
and to identify issues that need to be addressed before
frailty measures can be used for the evaluation of
interprofessional care for older populations.
FRAILTY CONCEPTS AND MEASURES
Frailty has been defined as ‘a precarious balance between
the assets maintaining health and the deficits threatening it’
(Rockwood, Fox, Stolee, Robertson, & Beattie, 1994). This
implies that a change in one variable may initiate a chain
reaction among others, leading to serious adverse con-
sequences for the individual. The definition leaves open the
identification of the key assets and deficits. In older people
these may be manifold, and they may interact. Physical,
cognitive, emotional and social factors become increasingly
interdependent with age, influencing health and well-being
in complex ways. The impacts of individual elements
such as nutrition, cognition and social functioning become
difficult to map, whereas in combination they can be
predictive of important outcomes such as ill health, moves
to care homes and death (Markle-Reid & Browne, 2003). If
frailty is operationalised, it can provide a measure of their
combined impact on the individual. Such a holistically
defined measure has obvious appeal for use in interprofes-
Frailty may be conceptualised as a clinical syndrome,
diagnosed by the presence of particular disorders and
physical characteristics, or as a progressive state of
dependency and vulnerability stemming from multiple
sources and risks. The former models tend to describe
frailty entirely or primarily in physical terms; the latter
incorporate additional domains such as the psychological
and social. This variation does not necessarily represent
disagreement about the ‘true’ nature of frailty. Models may
serve different purposes and capture different populations: a
study applying several commonly-used frailty criteria to a
single group of older people produced prevalence rates
between 33% and 88% (van Iersel & Rikkert, 2006). It may
be that the various models of frailty represent alternate
pathways to adverse outcomes (Cigolle, Ofstedal, Tian, &
The varying definitions of frailty have generated
numerous instruments for its measurement. Almost all
consider physical factors such as strength, balance, gait and
mobility (Levers, Estabrooks, & Ross Kerr, 2006). The use of
medications, the presence of specific disorders and func-
tional performance are also commonly assessed. Instru-
ments that focus only on the physical domain have been
challenged, however, and a more comprehensive model has
been advocated, including psychological, emotional, social,
spiritual and environmental components (Levers et al.,
2006; Markle-Reid & Browne, 2003). A recently-developed
measure of ‘social vulnerability’ incorporates a comprehen-
sive battery of personal and social factors such as ability to
speak the first language of the surrounding population,
attitude to the local neighbourhood and engagement in local
groups and faith communities (Andrew, Mitnitski, &
Rockwood, 2008). The resulting index is associated with
mortality, suggesting that such features may be important
L. POLTAWSKI ET AL.
Journal of Interprofessional Care
components or indicators of health status. It is unlikely that
they are mere products or consequences of physical/
biological deficits: in this index social vulnerability was
found to be associated with a frailty index based primarily
on physical factors, but was distinct from it.
Although the earlier dominance of biophysical markers
in assessment instruments has been challenged, new models
are still emerging with an exclusively or primarily physical
focus (Pel-Littel, Schuurmans, Emmelot-Vonk, & Verhaar,
2009; Walston et al., 2006). This stance might be justified
because several such scales have demonstrated predictive
validity for adverse outcomes such as morbidity and – often
portrayed as adverse but not necessarily so – moves to a
care home. Uncertainty remains about which factors have
most predictive significance, whether there are different
forms of frailty with their own particular risk factors, and
if there are still other factors that should be incorporated
into the models (Walston, et al., 2006). An integrated
model of frailty reflects the interprofessional working
paradigm, which seeks to address the connectedness of
multiple domains. Increasingly, frailty measures based on
this broader conceptualisation are being developed.
The data collected by frailty instruments may overlap
with that obtained by other tools such as the SF-36 Health
Scale (Garratt, Ruta, Abdalla, Buckingham, & Russell, 1993)
and the Barthel Functional Index (Reeves et al., 2010),
which are more familiar in healthcare than in social care.
However, many of these scales were not developed
specifically for use with older people or in community
settings, and the reliability of some of them for these
applications has been questioned (Brazier, Walters, Nicholl,
& Kohler, 1996; Sainsbury, Seebass, Bansal, & Young, 2005).
Several frailty tools, on the other hand, have been developed
specifically for use with older people in community settings,
and focus on issues that are particularly pertinent to them.
Numerous instruments have been developed for the
measurement of frailty. Their structures and processes of
application vary according to the concept of frailty adopted
and the purposes for which they are intended. These include
case identification, stratification of risk and monitoring
change (De Lepeleire, et al., 2009). So, for example, an
instrument commonly cited in the healthcare literature is
the Frailty Phenotype (Fried et al., 2001), which con-
ceptualises frailty as a reduction in physical capacity and
reserves, causing vulnerability to adverse outcomes. It uses
purely physical markers such as weight loss and grip
strength. The measure has been found predictive of a variety
of outcomes, such as increasing disability and dependence
(Avila-Funes et al., 2008) and incidence of thromboembo-
lism (Folsom et al., 2007), and so can be used to predict
support needs. Another measure, the Frailty Outcome
Prognosis, uses a more multidimensional conceptualisation
of frailty, and addresses socio-demographic, functional and
cognitive domains as well as medical and physical factors
(Ravaglia et al., 2008). It is predictive of mortality, fractures,
hospital admissions and worsening disability. Its developers
proposed that it could be used as an easy-to-administer but
powerful indicator of health status when a more compre-
hensive geriatric assessment is impractical (Ravaglia et al.,
APPLYING FRAILTY SCALES IN THE
The concept of frailty and its measurement has unexplored
potential in interprofessional working with community-
dwelling older people. Frailty instruments may assist in the
identification of individuals requiring complex care; they
can provide a motivator for different health and social care
practitioners to co-ordinate their goals and care plans. In
particular, they can be used to evaluate care according to
person-centred outcomes, rather than focussing exclusively
on process-oriented variables, such as shared communica-
tion systems, which may be necessary but insufficient to
promote health and well-being. To date, little attention has
been given to their application in this context, and so the
following observations are proposals rather than descrip-
tions of current practice.
Where frailty data are available for community-dwelling
older people in a particular locality, joint commissioners or
purchasers of services – such as local government and
health service partnerships – could use it to identify high-
risk groups and prioritise interprofessional projects. So, for
example, teams of social workers, nurses and physical
therapists could be given a specific remit to address groups
with high frailty scores. Interprofessional teams may use
frailty scores for the triage of referrals, assigning priority to
those identified as at higher risk by their scores.
Since many elements of frailty measures – such as levels
of medication, physical activity and community engagement
– may be inter-dependent, the frailty profile of an individual
can encourage the team practitioners to joint discussion and
planning of interventions. Case conferences involving the
older person can help set goals that are informed by the
high scoring elements of frailty. The particular value of
using a single instrument is that, if well-designed, it will
provide a concise, person-centred, commonly understood
framework for these discussions. Frailty instruments with
predictive validity will provide data that can confidently be
used to inform prioritisation of emerging goals and
proposed interventions. This may be particularly important
where resources are constrained, or competed for by the
different professions represented on the team. As frailty
research generates new insights into the relationships
between different elements of frailty – physical, psycholo-
gical and social – practitioners may be better informed
about the causal links and cascades that precipitate adverse
events. Focussed joint working may be used to target those
interactions known to be key to these cascades.
Most frailty instruments are designed to be administered
by a single practitioner. In some cases this may be a
geriatrician, but in others the assessment can be conducted
by a non-specialist (see below for examples). Where a
limited number of specialist skills are required, for example
in assessing cognition or grip strength, members of an
interprofessional team could train each other for these
? 2011 Informa UK, Ltd.
specific tasks. This would encourage focussed dialogue
between the professions and deepen the appreciation of
each others’ concerns. Joint assessments using the frailty
instrument would serve a similar purpose. In any case,
conducting a focussed frailty assessment could reduce the
number of discipline-specific measures required in each
case, or identify where such measures were particularly
appropriate. It might be part of a common assessment
process that could be less demanding of the older person
and practitioners’ time.
Some frailty instruments have the potential to monitor
the effects of interventions and to chart significant changes
in the individual’s well-being and vulnerability. These have
potential as evaluative tools in interprofessional working.
This application is addressed in more detail in the following
FRAILTY SCALES FOR THE EVALUATION OF
Frailty can be seen as a progressive characteristic and one
that may be slowed, interrupted or even reversed (De
Lepeleire et al., 2009; Gill, Gahbauer, Allore, & Han, 2006).
Measures using this dynamic model may be employed to
monitor an individual’s frailty status and identify significant
changes that are occurring over time, so providing data than
can assist decision-making and care-planning. They can also
be employed as outcome measures to evaluate care at
individual, group and organisational levels. Where different
structures and processes of interprofessional working are
being implemented with particular populations of older
people, frailty scoring systems may be used to judge and
compare their effectiveness. A number of instruments have
been developed that may have particular value in this regard:
. The Clinical Global Impression of Change in Physical
Frailty (Studenski et al., 2004) focuses, as its name
suggests, on physical factors, but also addresses self-
perceived health, emotional status and social interactions.
It was specifically designed to measure changes in health
status and quantifies the subjective judgement of a
clinician following a comprehensive assessment. It con-
ceptualises psychosocial status as a consequence of
physical frailty, and this may be challenged, but need not
affect implementation of the scoring system.
. The EdmontonFrailty
Tsuyuki, Tahir, & Rockwood, 2006) was constructed for
use by a non-specialist as a simple screening tool for
frailty: reaching a defined score threshold is deemed a
referral criterion for a comprehensive geriatric assessment.
The originators of the scale proposed that it could also be
used as a measure of change in health status and well-
being, although it does not yet appear to have been used
for this purpose.
. The Dynamic Frailty Scale (Puts, Lips, Dorly, & Deeg,
2005), was developed to identify those with moderate
levels of frailty, is conceptualised as an evolving state of
vulnerability to adverse outcomes, and is operationalised
in physical, cognitive and affective terms. Its developers
proposed that it could be useful in identifying moderately
frail individuals whose risk of admission to a nursing
home may be reduced by appropriate interventions.
Effective interventions should therefore be indicated by
Although these examples share a model of frailty as a
characteristic amenable to change by intervention, they
draw on different theoretical constructs and measure it in
quite different ways. Instruments that address multiple
domains are more likely to be of relevance to interprofes-
sional working, particularly where they involve both health
and social care practitioners. Some measures are based
entirely on assessments and opinions provided by a
practitioner; others draw upon responses by the individual
being assessed, or may use multiple sources of information.
Whilst scoring systems that rely on professional opinion
alone may take the patient’s/user’s experience and views
into account, a scale that incorporates both objective clinical
and subjective user-rated elements sits most comfortably in
a person-centred paradigm of care.
A frailty scale with proven predictive validity for
significant changes in the individual’s status – such as their
sense of well-being or the occurrence of adverse events –
has clear utility as an outcome measure for the evaluation of
interventions. In trials comparing different models of
interprofessional working, such scales could be used as
eligibility criteria to ensure that participants are similar at
baseline in terms of likelihood of particular outcomes.
Parallel arm trials with assessments at multiple time points
could be used to compare effectiveness in reducing risk and
charting how quickly such reductions occur. The challenges
of conducting and analysing multimodal interventions with
clustered participants would be the same as those in
evaluating other complex management strategies, but
strategies exist to optimise analytical power in these
contexts. Broad adoption of particular frailty scales with
proven inter-rater reliability would facilitate the meta-
analysis of different trials, so providing more convincing
evidence about the relative effectiveness of different
examples of interprofessional working.
CHALLENGES IN THE USE OF FRAILTY SCALES
Several issues must be addressed before frailty scales can
be used reliably for the evaluation of interprofessional
working. In particular, there is a need for consensus on the
constituent factors that must be included in the measure. A
suitable instrument will capture a situation that has
meaning and relevance for a range of professionals, and
do so succinctly. Determining the minimum necessary
dataset, and whether particular combinations of elements
are reliable predictors of outcome, may enable instruments
to be developed that are powerful, discriminatory and
feasible in practice. Although the concept of frailty is
gaining currency in healthcare settings and by healthcare
practitioners, in the UK context social care practitioners
L. POLTAWSKI ET AL.
Journal of Interprofessional Care
work within other paradigms such as opportunities and
inclusion (Knapp et al., 2005). Conceptualisations and
measures of frailty may address these concepts using other
terminology, but ongoing debate and collaboration between
those involved in health and social care are required to
develop a shared conceptualisation and idiom.
Standard protocols for the creation of health measure-
ment scales appear rarely to have been adopted in the
development of frailty instruments, and their validity,
reliability and responsiveness need to be formally estab-
lished. Frail older people appear rarely to have been
involved in the construction of frailty models or the
assessment instruments arising from them. Where they are
consulted, their views do not necessarily accord with those
of clinicians. In one consultation involving both clinicians
and healthcare users in the construction of a frailty
instrument (Studenski et al., 2004), patients and families
prioritised emotional and social issues most highly, whereas
clinicians gave equal weight to ‘intrinsic’ markers – such
as strength and balance – and ‘consequences’ – such as
functional independence and psychosocial status. This
biomedical model appears to marginalise what older people
believe by conceptualising social roles and psychological
functioning as arising from physical frailty, rather than as
components of frailty in their own right.
In a recent study, 25 older people were asked about their
own conceptions of frailty (Puts, Shekary, Widdershoven,
Heldens, & Deeg, 2009). Similar dimensions to those
employed in existing models emerged, but different or
additional markers were used to operationalise them. In
the physical domain, appearance and reliance on assistive
technology were seen as important indicators. Fear of
falling or of crime was identified in the psychological
domain, and loneliness and not being able to visit people
were suggested as social markers. Several people who had
been classified as frail by a validated instrument did not
see themselves as such, and no mention was made by
respondents of the physical markers used in that instru-
ment. It appears that the clinicians and patients had quite
different understandings of frailty (though both might have
significant implications for health and social care). More
personal experiential markers may need to be incorporated
into frailty instruments.
Conceptualisations of frailty have tended to produce
measures that focus on characteristics of the individual, and
this approach has been criticised because it does not take
account of wider contextual factors that may also impact
upon vulnerability (Markle-Reid & Browne, 2003). In fact,
vulnerability may be a more appropriate term than frailty to
describe a susceptibility to outcome that is dependent both
on individual and environmental features. Housing and
transport, as well as broader factors such as social attitudes
and cultural norms, may influence the susceptibility of the
individual to declining health (Ory, Kinney Hoffman,
Hawkins, Sanner, & Mockenhaupt, 2003). Models and
measures of frailty/vulnerability have yet to consider these
possibilities, and viable ways to quantify and incorporate
contextual factors into measures are required.
Debate continues regarding the definition of frailty and
its operationalisation for different purposes. At present,
debate about the conceptualisation, measurement and
application of frailty scales is largely being conducted
within healthcare settings and by healthcare practitioners.
In the UK context at least, the activities of many social care
practitioners are governed by other influences, such as need
and risk. Embedding frailty within such needs assessments
would require collaborative work and piloting of tools that
emerge. The language of social care outcomes for adults
may also provide opportunities to debate the potential of
using terms and measures of frailty, but it is in social care
that the most sustained critiques of frailty as a term are to
be found, with some (Knapp et al., 2005) arguing that
greater emphasis should now be placed on needs defined in
terms of opportunities and inclusion. Hence, the discussion
needs to incorporate the different perspectives of social and
health care, as well as those of older people and their carers.
Out of such dialogue, a model and measure of frailty may
emerge that both reflects an interdisciplinary approach and
can be used to promote and evaluate it.
The concept of frailty is receiving increasing attention in
the healthcare literature. Frailty instruments can address
multiple interacting domains, draw upon the expertise of
practitioners and the experiences of older people, and
some are capable of registering changes in an individual’s
vulnerability to adverse outcomes. Hence, they have
considerable potential in the identification, risk stratifica-
tion and care management of older people with complex
conditions living in the community. In our view they may
also prove invaluable in assessing the impact of inter-
professional working with this group. Research and practice
can inform the validation of existing measures and the
development of new ones for this purpose. Joint exploration
of a holistic and integrated model of frailty, and develop-
ment of responsive measures based upon it, have the
potential to draw the different disciplines in health and
social care into a productive debate about care needs and
service priorities. The dividend of such efforts may be user-
centred models and measures of frailty/vulnerability that
are of particular value where multiple factors producing
health and well-being interact, and where professionals
from different organisations and disciplines are working
together with older people and carers.
Declarations of interest
The authors report no conflict of interest. The authors alone
are responsible for the content and writing of the paper
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