Original Article| Volume 67, ISSUE 2, P176-183, February 2014

Download started.


Construct validity and reliability of a two-step tool for the identification of frail older people in primary care

Published:November 04, 2013DOI:



      To study the reliability and construct validity of the EASY-Care Two-step Older persons Screening (EASY-Care TOS), a practice-based tool that helps family physicians (FPs) to identify their frail older patients.

      Study Design and Setting

      This validation study was conducted in six FP practices. We determined the construct validity by comparing the results of the EASY-Care TOS with other commonly used frailty constructs [Fried Frailty Criteria (FFC), Frailty Index (FI)] and with other related constructs (ie, multimorbidity, disability, cognition, mobility, mental well-being, and social context). To determine interrater reliability, an independent second EASY-Care TOS assessment was made for a subpopulation.


      We included 587 older patients (mean age 77 ± 5 years, 56% women). According to EASY-Care TOS, 39.4% of patients were frail. EASY-Care TOS frailty correlated better with FI frailty (0.63) than with FFC frailty (0.52). A high correlation was found with multimorbidity (0.50), disabilities (0.53), and mobility (0.55) and a moderate correlation with cognition (0.31) and mental well-being (0.38). Reliability testing showed 89% agreement (Cohen's κ 0.63) between EASY-Care TOS frailty judgment by two different assessments.


      EASY-Care TOS correlated well with relevant physical and psychosocial measures. Accordingly, these results show that the EASY-Care TOS identifies patients who have a wide spectrum of interacting problems.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Clinical Epidemiology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Iliffe S.
        Family medicine in an aging society.
        Can Fam Physician. 2009; 55: 463-467
        • Boeckxstaens P.
        • De Graaf P.
        Primary care and care for older persons: position paper of the European Forum for Primary Care.
        Qual Prim Care. 2011; 19: 369-389
        • Wilhelmson K.
        • Duner A.
        • Eklund K.
        • Gosman-Hedstrom G.
        • Blomberg S.
        • Hasson H.
        • et al.
        Design of a randomized controlled study of a multi-professional and multidimensional intervention targeting frail elderly people.
        BMC Geriatr. 2011; 11: 24
        • Eklund K.
        • Wilhelmson K.
        Outcomes of coordinated and integrated interventions targeting frail elderly people: a systematic review of randomised controlled trials.
        Health Soc Care Community. 2009; 17: 447-458
        • De Lepeleire J.
        • Iliffe S.
        • Mann E.
        • Degryse J.M.
        Frailty: an emerging concept for general practice.
        Br J Gen Pract. 2009; 59: e177-e182
        • Lacas A.
        • Rockwood K.
        Frailty in primary care: a review of its conceptualization and implications for practice.
        BMC Med. 2012; 10: 4
        • Pialoux T.
        • Goyard J.
        • Lesourd B.
        Screening tools for frailty in primary health care: a systematic review.
        Geriatr Gerontol Int. 2012; 12: 189-197
        • Rockwood K.
        • Mitnitski A.
        Frailty in relation to the accumulation of deficits.
        J Gerontol A Biol Sci Med Sci. 2007; 62: 722-727
        • Fried L.P.
        • Tangen C.M.
        • Walston J.
        • Newman A.B.
        • Hirsch C.
        • Gottdiener J.
        • et al.
        Frailty in older adults: evidence for a phenotype.
        J Gerontol A Biol Sci Med Sci. 2001; 56: M146-M156
        • Mitnitski A.
        • Song X.
        • Skoog I.
        • Broe G.A.
        • Cox J.L.
        • Grunfeld E.
        • et al.
        Relative fitness and frailty of elderly men and women in developed countries and their relationship with mortality.
        J Am Geriatr Soc. 2005; 53: 2184-2189
        • Romero-Ortuno R.
        • Walsh C.D.
        • Lawlor B.A.
        • Kenny R.A.
        A frailty instrument for primary care: findings from the Survey of Health, Ageing and Retirement in Europe (SHARE).
        BMC Geriatr. 2010; 10: 57
        • Drubbel I.
        • de Wit N.J.
        • Bleijenberg N.
        • Eijkemans R.J.
        • Schuurmans M.J.
        • Numans M.E.
        Prediction of adverse health outcomes in older people using a frailty index based on routine primary care data.
        J Gerontol A Biol Sci Med Sci. 2013; 68: 301-308
        • Gobbens R.J.
        • Luijkx K.G.
        • Wijnen-Sponselee M.T.
        • Schols J.M.
        Toward a conceptual definition of frail community dwelling older people.
        Nurs Outlook. 2010; 58: 76-86
        • Sternberg S.A.
        • Wershof Schwartz A.
        • Karunananthan S.
        • Bergman H.
        • Mark Clarfield A.
        The identification of frailty: a systematic literature review.
        J Am Geriatr Soc. 2011; 59: 2129-2138
        • van Kempen J.A.
        • Schers H.J.
        • Jacobs A.
        • Zuidema S.U.
        • Ruikes F.
        • Robben S.H.
        • et al.
        Development of an instrument for the identification of frail elderly as a target population for integrated care.
        Br J Gen Pract. 2013; 63: e225-e231
        • Nourhashemi F.
        • Andrieu S.
        • Gillette-Guyonnet S.
        • Vellas B.
        • Albarede J.L.
        • Grandjean H.
        Instrumental activities of daily living as a potential marker of frailty: a study of 7364 community-dwelling elderly women (the EPIDOS study).
        J Gerontol A Biol Sci Med Sci. 2001; 56: M448-M453
        • Keiren S.M.
        • van Kempen J.A.
        • Schers H.J.
        • Olde Rikkert M.G.
        • Perry M.
        • Melis R.J.
        Feasibility evaluation of a stepped procedure to identify community-dwelling frail older people in general practice. A mixed methods study.
        Eur J Gen Pract. 2013; (In press)
        • Strawbridge W.J.
        • Shema S.J.
        • Balfour J.L.
        • Higby H.R.
        • Kaplan G.A.
        Antecedents of frailty over three decades in an older cohort.
        J Gerontol B Psychol Sci Soc Sci. 1998; 53: S9-S16
        • Bandeen-Roche K.
        • Xue Q.L.
        • Ferrucci L.
        • Walston J.
        • Guralnik J.M.
        • Chaves P.
        • et al.
        Phenotype of frailty: characterization in the women's health and aging studies.
        J Gerontol A Biol Sci Med Sci. 2006; 61: 262-266
        • Rockwood K.
        • Hogan D.B.
        • MacKnight C.
        Conceptualisation and measurement of frailty in elderly people.
        Drugs Aging. 2000; 17: 295-302
        • Schuurmans H.
        • Steverink N.
        • Lindenberg S.
        • Frieswijk N.
        • Slaets J.P.
        Old or frail: what tells us more?.
        J Gerontol A Biol Sci Med Sci. 2004; 59: M962-M965
        • Richardson J.
        The Easy-Care assessment system and its appropriateness for older people.
        Nurs Older People. 2001; 13: 17-19
        • Rockwood K.
        • Andrew M.
        • Mitnitski A.
        A comparison of two approaches to measuring frailty in elderly people.
        J Gerontol A Biol Sci Med Sci. 2007; 62: 738-743
        • Salvi F.
        • Miller M.D.
        • Grilli A.
        • Giorgi R.
        • Towers A.L.
        • Morichi V.
        • et al.
        A manual of guidelines to score the modified cumulative illness rating scale and its validation in acute hospitalized elderly patients.
        J Am Geriatr Soc. 2008; 56: 1926-1931
        • Folstein M.F.
        • Folstein S.E.
        • McHugh P.R.
        “Mini-mental state”. A practical method for grading the cognitive state of patients for the clinician.
        J Psychiatr Res. 1975; 12: 189-198
        • de Rooij S.E.
        • Govers A.C.
        • Korevaar J.C.
        • Giesbers A.W.
        • Levi M.
        • de Jonge E.
        Cognitive, functional, and quality-of-life outcomes of patients aged 80 and older who survived at least 1 year after planned or unplanned surgery or medical intensive care treatment.
        J Am Geriatr Soc. 2008; 56: 816-822
        • Guralnik J.M.
        • Simonsick E.M.
        • Ferrucci L.
        • Glynn R.J.
        • Berkman L.F.
        • Blazer D.G.
        • et al.
        A short physical performance battery assessing lower extremity function: association with self-reported disability and prediction of mortality and nursing home admission.
        J Gerontol. 1994; 49: M85-M94
        • Yesavage J.A.
        • Brink T.L.
        • Rose T.L.
        • Lum O.
        • Huang V.
        • Adey M.
        • et al.
        Development and validation of a geriatric depression screening scale: a preliminary report.
        J Psychiatr Res. 1982; 17: 37-49
        • Zigmond A.S.
        • Snaith R.P.
        The hospital anxiety and depression scale.
        Acta Psychiatr Scand. 1983; 67: 361-370
        • Hays R.D.
        • Sherbourne C.D.
        • Mazel R.M.
        The RAND 36-item health survey 1.0.
        Health Econ. 1993; 2: 217-227
        • Cohen J.
        A power primer.
        Psychol Bull. 1992; 112: 155-159
        • Cigolle C.T.
        • Ofstedal M.B.
        • Tian Z.
        • Blaum C.S.
        Comparing models of frailty: the Health and Retirement Study.
        J Am Geriatr Soc. 2009; 57: 830-839
        • van Iersel M.B.
        • Rikkert M.G.
        Frailty criteria give heterogeneous results when applied in clinical practice.
        J Am Geriatr Soc. 2006; 54: 728-729
        • Sourial N.
        • Wolfson C.
        • Bergman H.
        • Zhu B.
        • Karunananthan S.
        • Quail J.
        • et al.
        A correspondence analysis revealed frailty deficits aggregate and are multidimensional.
        J Clin Epidemiol. 2010; 63: 647-654
        • Martin F.C.
        • Brighton P.
        Frailty: different tools for different purposes?.
        Age Ageing. 2008; 37: 129-131
        • Collard R.M.
        • Boter H.
        • Schoevers R.A.
        • Oude Voshaar R.C.
        Prevalence of frailty in community-dwelling older persons: a systematic review.
        J Am Geriatr Soc. 2012; 60: 1487-1492