i sciendo Zdr Varst. 2019;58(2):91-100 10.2478/sjph-2019-0012 Dolenc E, Rotar-Pavlic D. Frailty assessment scales for the elderly and their application in primary care: a systematic literature review. Zdr Varst. 2019;58(2):91-100. doi: 10.2478/sjph-2019-0012. FRAILTY ASSESSMENT SCALES FOR THE ELDERLY AND THEIR APPLICATION IN PRIMARY CARE: A SYSTEMATIC LITERATURE REVIEW OCENJEVALNE LESTVICE KRHKOSTI STAROSTNIKA IN NJIHOVA RABA NA PRIMARNI RAVNI: SISTEMATIČNI PREGLED LITERATURE Eva DOLENC1*, Danica ROTAR-PAVLIČ2 'University of Ljubljana, Faculty of Health Sciences, Zdravstvena pot 5, 1000 Ljubljana, Slovenia 2University of Ljubljana, Faculty of Medicine, Department of Family Medicine, Poljanski nasip 58, 1000 Ljubljana, Slovenia Received: Apr 16, 2018 Accepted: Feb 22, 2019 Review ABSTRACT Keywords: elderly, frailty, assessment scales, primary care IZVLEČEK Ključne besede: starostniki, krhkost, ocenjevalne lestvice, primarno zdravstveno varstvo Background: The increase in the elderly population is causing changes and challenges that demand a comprehensive public health response. A specific characteristic of the elderly is their frailty. Today's problems with identifying levels of frailty are being resolved by numerous tools in the form of frailty assessment scales. This systematic review establishes which frailty assessment scales for the elderly are being used and what their applicability in primary care is like in Slovenia and around the world. Methods: Documents published after 2010 were searched for in the PubMed database using keywords and other specific criteria. Results: A total of 177 search hits were obtained based on various search strings. The final analysis included 28 articles, of which three were systematic literature reviews. These three covered quantitative studies, mainly consisting of observational cross-sectional surveys or cohort studies. Three other studies featured non-systematic literature reviews. Quantitative studies (mainly cross-sectional surveys or cohort studies) prevailed among the remaining 22 articles. One study had a qualitative design (Delphi method). The main outcome measures observed by all studies were frailty assessment scales for the elderly, the majority of which were evaluated on a sample of the elderly. Conclusions: None of the assessment scales examined are used as the gold standard for primary care. A variety of tools are being used in clinical practice to assess frailty in elderly patients, highlighting the need for standardization and guidelines. This requires evaluating the current assessment scales in terms of validity and reliability, and suitably improving them. Uvod: Povečan delež starejšega prebivalstva povzroča spremembe in prinaša izzive, kar zahteva celovit odziv na področju javnega zdravja. Specifičnost starostnikov je tudi njihova krhkost. Ta za posameznika pomeni večje tveganje za negativne rezultate, povezane z zdravjem. Ugotavljanje krhkosti daje teoretični okvir, v katerem lahko zdravnik primarnega zdravstvenega varstva oblikuje celovit pristop ocenjevanja in zdravljenja starejšega bolnika s kompleksno multimorbidnostjo na preprost in strukturiran način. Težave določanja stopnje krhkosti danes rešujejo številna orodja v obliki ocenjevalnih lestvic krhkosti. Slovenija se je v letu 2017 pridružila Evropski komisiji pri Skupnem evropskem ukrepanju za preprečevanje starostne krhkosti in oslabljenosti »Joint Action«. Eden izmed predlogov ukrepov in aktivnosti je tudi razviti, implementirati in spremljati sistem presejanja na krhkosti po posameznih področjih. Sicer z merjenjem krhkosti lahko pridobimo uporabne podatke, a je za oblikovanje informacij pomemben izbor ustreznega, veljavnega instrumenta. Pojavlja se vprašanje o količini in kakovosti uporabe ocenjevalnih lestvic krhkosti starostnikov. Namen sistematičnega pregleda literature je ugotoviti, katere ocenjevalne lestvice merjenja krhkosti starostnika se uporabljajo in kakšna je domnevna uporabnost na primarni ravni v svetu in v Sloveniji. Metode: Sistematično je bila pregledana literatura, objavljena po letu 2010, o ocenjevalnih lestvicah krhkosti starostnika. Iskanje dokumentov je potekalo v bibliografski bazi PubMed po določenih kriterijih s ključnimi besedami: frailty, elderly, evaluation scale, primary, frailty scale, frailty screening in primary care. Rezultati: Vseh zadetkov glede na različne iskalne nize je bilo 177. V končno analizo se je uvrstilo 28 člankov, od tega trije sistematični pregledi literature. Ti vključujejo kvantitativne raziskave, v večini opazovalne presečno pregledne ali kohortne študije. Tri raziskave so nesistematični pregledi literature. Med 22 drugimi raziskavami prevladujejo raziskave s kvantitativnimi zasnovami, v večini so presečno pregledne ali kohortne študije. Ena študija ima kvantitativno zasnovo, zbiranje podatkov pa je potekalo z delfsko metodo. Opazovani izidi vseh študij so ocenjevalne lestvice starostnikov. V večini so jih raziskovalci vrednotili na vzorcu starostnikov. Zaključki: Zaradi starajočega se prebivalstva je potreba po ureditvi področja merjenja krhkosti starostnikov s pomočjo ocenjevalnih lestvic vse večja. Za ugotavljanje krhkosti starejših se v praksi uporablja toliko orodij, da je potreba po standardizaciji in smernicah velika. Nobena izmed ocenjevalnih lestvic nima vloge zlatega standarda uporabe za primarno raven. Pred implementacijo v slovenski prostor je potrebno obstoječe ocenjevalne lestvice vrednotiti po kriterijih veljavnosti in zanesljivosti ter jih primerno izboljšati. Corresponding author: Tel. + 386 40 741 191; E-mail: eva.dolenc@zf.uni-lj.si NIJZ National Institute © National Institute of Public Health, Slovenia. 91 of Public Health This work is licensed under the Creative 23.03.20 10:51 UTC 10.2478/sjph-2019-0012 Zdr Varst. 2019;58(2):91-100 1 INTRODUCTION The population's age structure has been changing greatly over the past decades, with the population becoming increasingly older, including in Slovenia (1, 2). This causes many changes and challenges that demand a comprehensive public health response (3, 4). A specific characteristic of the elderly is their frailty. It is defined as "a condition or syndrome which results from a multi-system reduction in reserve capacity to the extent that a number of physiological systems are close to, or past, the threshold of symptomatic clinical failure." As a consequence, the frail person is at increased risk of disability and death from minor external stresses (5). Identifying the level of frailty is a useful clinical concept for predicting and preventing frailty (6-8). Frailty in the elderly entails a changed perspective on age by replacing the outdated term "chronological age" with the more accurate and personalized parameter of "biological age," and it can be measured in individuals (9). Problems with identifying the level of frailty, which were common in the past (5), are now being solved by numerous tools that can also be applied to the elderly (10, 11). Frailty assessment thus provides a theoretical framework that primary care physicians can use to develop a comprehensive approach to assessing and treating elderly patients with complex multimorbidity in a simple and structured way (7). In Slovenia, an important role in this regard is also played by family doctors and their teams (12). The importance of using frailty measurement tools is supported by the global lack of key information and evidence on the health of the elderly, which hinders the development and evaluation of suitable policies and programs for them (13). Frailty measurements can generally provide useful information, but that requires selecting an appropriate valid instrument (9). In agreement with the Ministry of Health, in 2017, Slovenia joined the EU Commission's Joint Action on the Prevention of Frailty. The main outcome of Joint Action will be a common European model to approach frailty, leading to the development of improved strategies for diagnosis care and education for frailty, disability and multi-morbidity. The Joint Action outcomes are expected to contribute to the prevention of the growing burden of disability and chronic diseases and to a more effective response to older people's needs of care delivery, a central priority for the EU and its MS. One of the measures and activities proposed was to develop, implement, and monitor a frailty screening system by individual area (14). The question is how many frailty assessment scales are available and what their quality is like. In Slovenia, there is a need for the knowledge of frailty assessment scales for the application at the primary level. They established the subject of Geriatrics and subject Elderly, dying patient, palliative at the Faculty of Medicine at the University of Ljubljana. In Slovenia, payment models for multimorbidity and elderly are also changing. This literature review identifies research on frailty assessment scales for the elderly published after 2010. Its goals were to determine which frailty assessment scales are available, what they measure, and whether they are used in primary care. The fundamental research question is whether the knowledge on frailty assessment scales provides a selection of assessment scales that could be applied to primary care in Slovenia in order to assess the frailty of the elderly. 2 METHODS Literature on frailty assessment scales for the elderly was systematically reviewed. The data was collected in February 2018. 2.1 Document Sources Documents were searched for in the online bibliographical database PubMed (15). 2.2 Document Identification Methods Documents were searched for using the following keywords: frailty, elderly, evaluation scale, primary, frailty scale, frailty screening, and primary care. Searches were performed using Boolean operators for PubMed: (((frailty) AND elderly) AND evaluation scale); (((frailty) AND elderly) AND rating scale); (((frailty) AND elderly) AND measuring); ((frailty) AND screening) AND primary care). The search was limited to full-text open-access English articles published after 2010. 2.3 Methods of Selecting Documents to be Included in the Analysis The selection in PubMed was narrowed down to full-text research articles. The keywords selected had to be included in the article's title or abstract, the articles had to refer to the elderly, and they had to be written in English and published in the past 8 years. An article was deemed appropriate if it featured a study connected with the frailty assessment scales used for the elderly. Studies containing clinical frailty scales or scales used for populations other than the elderly and clinical frailty scales were not included. After selecting the relevant articles, an open discussion took place in a heterogeneous group of experts with diplomas from the Faculty of Medicine and Faculty of Health Sciences at the University of Ljubljana and head lecturer of subject Determinants of health and disease on Interdisciplinary doctoral programme in Biomedicine, field Public Health. Another discussion took place in a group of students specialized in Family Medicine from Faculty of Medicine at the subject Bereitgestellt von National & University Library Ljubljana | Heruntergeladen 23.03.20 10 :51 UTC 10.2478/sjph-2019-0012 Zdr Varst. 2019;58(2):91-100 Elderly, dying patient, palliative. Their suggestions and comments found a place in the final selection of articles and frailty assessment scales for eventual application in primary care. 2.4 Selection of Relevant Data for t he Systematic Review The data collected included year, country, research design, units observed, number of participants, and main conclusions. 2.5 Methods for Assessing Study Quality The suitability of the studies included was evaluated in terms of their agreement with the search string. 3.1 Selecting Documents for Systematic Review 3 RESULTS Twenty-eight articles meeting the selected for final analysis (Table 1). criteria set were 3.2 Main Characteristics of the Research Studies Reviewed This analysis includes three systematic literature reviews that together cover more than 70 quantitative studies, consisting largely of observational cross-sectional surveys or cohort studies. Three studies included in the final analysis are non-systematic literature reviews (Table 1). Studies found Rough review Accessibility Sources found by searching database, using several search strings (n=177) Sources after removing duplicates (n=160) Rough review of Sources excluded title and abstract in search hits (n=90) during first stage (n=46) Sources accessible in full text (n=44) Sources excluded during second stage (n=4) Sources reviewed in full (n=40) Sources excluded during third stage with reasons: clinical frailty scales, scales for population other than the elderly (n=12) Sources included in detailed review, analysis, and qualitative synthesis (n=28) Figure 1. The procedure of selecting documents for inclusion in the systematic review of literature on frailty assessment scales for the elderly and their application in primary care. Table 1. Main characteristics and results on frailty assessment scales for the elderly. Document Country No. of studies included in final analysis Research design Year studies were conducted Main conclusions Bouillon et al., 2013 (16) UK 27 Quantitative design: mostly cross-sectional studies 1948 -2011 Twenty-seven frailty scales were identified, but their reliability and validity were rarely evaluated. None of them are used as the gold standard. Vermeulen et al., 2011 (17) Netherlands 28 Quantitative design: longitudinal and cohort studies 1975 -2010 The strongest predictors are low physical activity and slow walking speed. Drubbel et al., 2014 (18) Netherlands 20 Quantitative design: one cross-sectional survey and 19 cohort studies 2001 -2012 The Frailty Index (FI) is a valid instrument for assessing frailty. Li et al., 2017 (19) Canada Non-systematic literature review 51 references Not provided Measuring the grades of frailty in the elderly could assist in the assessment, management, and decision-making for osteoporosis and osteoporotic fractures. Singh et al., 2014 (20) US Non-systematic literature review 101 references Not provided There are numerous frailty assessment scales available. Dawson and Dennison, 2016 (21) New Zealand Non-systematic literature review 36 references Not provided At present, while diagnostic tools have been developed to identify those with the condition (e.g. the PRISMA 7 questionnaire), as there are many conditions which frailty mimics, the problem of low specificity remains. Bereitgestellt von National & University Library Ljubljana | Heruntergeladen 23.03.20 10 :51 UTC 10.2478/sjph-2019-0012 Zdr Varst. 2019;58(2):91-100 Twenty-two studies from various countries, published after 2010, are dominated by quantitative, mostly cross-sectional or cohort studies. One study (22) has a qualitative design and data for it was collected using the Delphi method. The number of subjects included in the study depends on the research design, ranging from 100 to 5,000 in the majority of the studies; the age criteria used vary. Four studies include geriatric specialists: GPs, specialist physicians, and so on (22-25). Four studies (26-29) are based on databases that already exist. The main outcome measures observed by all studies are frailty assessment scales, indexes, or indicators analysed from various perspectives (Table 2). Table 2. Main characteristics and results on frailty assessment scales for the elderly. Document Country Research design No. of participants / Main outcome Main conclusions characteristics measures Roppolo et al., 2015 (30) Malmstrom et al., 2015 (31) Italy USA Romero-Ortuno et al., 2010 (26) Romero-Ortuno and Soraghan, 2014 (27) Ireland Ireland Jotheeswaran et al., 2016 (32) Uchmanowicz et al., 2014 (33) van Kempen et al., 2013 (34) India Quantitative design: cross-sectional study Quantitative design: longitudinal cohort study 267 community-dwelling elderly people 998 Afro-Americans, 49 to 65 years old Quantitative design: 17.304 women and 13.811 cross-sectional survey men over 50 included in the Survey of Health, Aging and Retirement in Europe (SHARE) Quantitative design: 4.001 women and 3.057 longitudinal population- men 75 or older from the based study Poland Netherlands Quantitative design: cross-sectional survey, group-based observational study, measurement instrument validation Quantitative design: cross-sectional survey, measurement instrument validation Quantitative design: observational pilot study, cross-sectional survey Survey of Health, Aging and Retirement in Europe (SHARE) 150 frail and/or care-dependent elderly people in the primary care setting 100 Polish patients 42 men and 58 women The Cardiovascular Health Study index and the Tilburg Frailty Indicator How well the International Academy of Nutrition and Aging (FRAIL) frailty scale predicts future disability compared to the Study of Osteoporotic Fractures (SOF) frailty scale, the phenotype-based Cardiovascular Health Study (CHS) frailty scale, and the comprehensive Frailty Index (FI) The authors created and validated a simple frailty screening instrument. seven academic GP The aim was practices in and around to describe the Nijmegen, the Netherlands; development of the a total of 151 patients were Easycare-TOS. included Different instruments capture different frail individuals. Combined use of instruments proves to be the best for predicting disability and mortality. The SHARE Frailty Instrument has sufficient construct and predictive validity. The mortality prediction of the SHARE-FI75+ was compared with that of previous frailty scales in SHARE (SHARE-FI, 70-item index, phenotype, FRAIL). Three primary care physicians administered EASY-Care comprehensive geriatric assessment. The aim was to adopt and test the validity of the Polish version of the TFI The SHARE-FI75+ could help identify frailty in primary care. Robust measurement properties. The TFI is a valid and reproducible instrument for assessing frailty among the Polish population. The instrument meets the efficiency, flexibility, and acceptability requirements for use in primary care. Bereitgestellt von National & University Library Ljubljana | Heruntergeladen 23.03.20 10 :51 UTC 10.2478/sjph-2019-0012 Zdr Varst. 2019;58(2):91-100 Document Country Research design No. of participants / characteristics Main outcome measures Main conclusions Morris et al., US Quantitative design: 464.788 people served by The aim was to present The instrument is based on a 2016 (28) cross-sectional survey, home care agencies the development and strong conceptual foundation. measurement instrument evaluation of the development, and interRAI HC Frailty evaluation Scale. van Kempen, Netherlands Quantitative design: six family practices and The aim was to Geriatricians assess patients et al., 2015 (23) cross-sectional, one geriatric department; compare the frailty as frail more often than family explorative 587 patients 70 or older assessments provided physicians. observational study registered in these by family physicians practices and geriatricians. Morley et al., US Qualitative design: delegates of six major The aim was to reach A report was produced based on 2013 (22) the Delphi method international, European, consensus on frailty. the consensus. and US societies, and seven other frailty specialists Castell et al., Spain Quantitative design: 1.327 people older than 65 The aim was to estimate Detection of a walking speed 2013 (35) cross-sectional study frailty based on the below 0.8 m/s is a simple walking speed of the approach to diagnosing frailty in elderly urban population primary care. and apply the findings to primary care. Eyigor et al., US Quantitative design: 1.126 people over 65 from The Fried frailty criteria, Age, female gender, low 2015 (36) cross-sectional 13 centres the Mini Nutritional education level, being a multicentre study Assessment, the Centre housewife, living with the family, for Epidemiological being sedentary, presence of an Studies Depression additional disease, using four or (CES-D) scale, the more drugs/day, avoiding going Charlson Comorbidity outside, at least one visit to any Index emergency department within the past year, hospitalization within the past year, non-functional ambulation, and malnutrition increase the risk of frailty. Drubbel et al., Netherlands Quantitative design: 1.580 patients 60 or older Whether a Frailty Index The FI and the GFI moderately 2013 (37) cross-sectional from a Dutch primary care (FI), based on ICPC- overlap in identifying frailty. observational study centre coded primary care Authors suggest an initial FI data, and the Groningen screening in routine healthcare Frailty Indicator (GFI) data, followed by a GFI questionnaire identify questionnaire for patients at the same older people high risk as the preferred two- as frail. step frailty screening process in primary care. Silva et al., Brazil Quantitative design: 345 elderly people Self-perceived health, Risk of falls, frailty, functional 2016 (38) cross-sectional anamnesis, Lawton performance on the Instrumental observational study and Brody's Scale, Activities of Daily Living, Katz Index, Geriatric insomnia, and familial support are Depression Scale, Timed related to self-perceived health. Up and Go Test, and Study of Osteoporotic Fracture Index Bertoli et al., Italy Quantitative design: 112 elderly subjects: 62 Thyroid stimulating Measuring FT3 can be a useful 2017 (39) cross-sectional were hospitalised following hormone (TSH), free laboratory parameter. observational study hip fracture and 50 control triiodothyronine (FT3), subjects were outpatients and free thyroxine (FT4) were measured to evaluate the prevalence of thyroid hormone modifications in elderly frail subjects and its relationship with frailty. Bereitgestellt von National & University Library Ljubljana | Heruntergeladen 23.03.20 10 :51 UTC 10.2478/sjph-2019-0012 Zdr Varst. 2019;58(2):91-100 Document Country Research design No. of participants / characteristics Main outcome measures Main conclusions Theou et al., Ireland Quantitative design: 4.961 elderly Irish residents Whether frailty Self-reported and test-based 2015 (40) longitudinal study assessment differs when measures should be combined constructing frailty when trying to identify levels of indices using solely self- frailty. reported or test-based health measures. van Kempen et al., Netherlands Quantitative design: 4.961 elderly Irish residents The aim was to GPs can predict negative 2015 (24) longitudinal primary a 587 patients of four GP determine the predictive health outcomes in their care registry-based practices in the Netherlands value of EASY-Care TOS older populations efficiently cohort study for negative health and almost as accurately as outcomes within the specialists in this area. year from assessment. Bruyère et al., Belgium, Quantitative design: 388 clinicians from 44 How practitioners 52.8% always assess frailty in 2017 (25) EU survey international online countries, mostly doctors measure the geriatric their daily practice and 64.9% of cross-sectional survey (93%), with geriatrics as syndrome of frailty in them diagnose frailty using more their primary field of their daily routine. than one instrument. practice (83%). Metzelthin et al., Netherlands Quantitative design: 687 community-dwelling The Groningen Frailty The GFI and the TFI showed 2010 (41) cross-sectional survey elderly people 70 or older. Indicator (GFI), the high internal consistency and Tilburg Frailty Indicator construct validity in contrast to (TFI), the Sherbrooke the SPQ. It is not yet possible to Postal Questionnaire conclude whether the GFI or the (SPQ), and the Groningen TFI should be preferred. The SPQ Activity Restriction Scale seems less appropriate for postal (GARS) screening of frailty. Lee et al., 2017 (42) Canada Quantitative design: Complete frailty screening The aim was to examine The use of gait speed or grip retrospective chart data were available for 383 the accuracy of strength alone was found to review patients75 and older. individual Fried frailty be sensitive and specific as phenotype measures a proxy for the Fried frailty in identifying the Fried phenotype, but the use of both frailty phenotype in measures together was found to primary care. be accurate, precise, specific, and more sensitive than other possible combinations. Assessing both measures is feasible within primary care. Campitelli et al., Canada Quantitative design: resident Assessment The aim was to examine The different approaches to 2016 (29) retrospective cohort Instrument (RAI) data for two versions of a detecting vulnerability resulted study all long-stay home care frailty index (a full and in different estimates of clients (66 or older) in a modified FI), and frailty prevalence. The gains in Ontario, Canada the CHESS scale, and predictive accuracy were often (n=234.552) compare their baseline modest with the exception of characteristics and their the full FI. predictive accuracy. Vergara et al., Spain Quantitative design: 900 individuals 70 or older The Tilburg Frailty Great potential for direct 2016 (43) prospective multicentre Indicator (TFI), the application in primary care. cohort study Gérontopôle Frailty Screening Tool (GFST), and the KoS model together with two biomarker levels (SOX2 and p16INK4a) for adverse events related to frailty. Bereitgestellt von National & University Library Ljubljana | Heruntergeladen 23.03.20 10 :51 UTC 10.2478/sjph-2019-0012 Zdr Varst. 2019;58(2):91-100 Table 3. Frailty assessment scales that were identified for eventual application in primary care. Frailty assessment scale Short description The FRAIL (22) The Cardiovascular Health Study Frailty Screening Measure (22) The SHARE Frailty Instrument (SHARE-FI) (26) The SHARE Frailty Instrument (SHARE-FI) 75+ (27) interRAI home care frailty scale (28) Study of Osteoporotic Fractures (SOF) frailty scale (31) Tilburg Frailty Indicator (TFI) (33, 41, 43) easycare Two-step Older persons Screening (Easycare-TOS) (24, 34) Frailty Index (FI) (37) Groningen Frailty Indicator (GFI) (25, 37, 41) Short Physical performance Battery (SPPB) (25) Edmonton frail scale (25) Frail scale status (25) Gerontopole frailty screening tool (GFST) (22, 25, 43) SEGA grid (25) Strawbridge questionnaire (25) Frailty phenotype (25, 44) fatigue, resistance, aerobic, illnesses, loss of weight weight loss, exhaustion, low activity, slowness, weakness exhaustion, weight loss, handgrip strength, slowness, low activity fatigue, low appetite, weakness, slowness. 29 assessment items; the areas of function, movement, cognition and communication, social life, nutrition and clinical symptoms weight loss, reduced energy level, inability to rise from a chair, reduced energy level Sociodemographic characteristics of a participant. The physical domain: physical health, unexplained weight loss, difficulty in walking, balance, hearing problems, vision problems, strength in hands, and physical tiredness. The psychological domain: cognition, depressive symptoms, anxiety, and coping. The social domain: living alone, social relations, and social support 14 questions about the functioning of the patient in somatic, psychological, and social domains includes 40 variable 15 self-report items and screens for loss of functions and resources in four domains: physical, cognitive, social, and psychological balance, 4-metre gait speed and chair stand test cognitive impairment, health attitudes, social support, medication use, nutrition, mood, continence, functional abilities fatigue, resistance, ambulation, illness and loss of weight The first 6 questions evaluate the patient's status (living alone, involuntary weight loss, fatigue, mobility difficulties, memory problems and gait speed), whereas the last two assess the general practitioner's personal view about the frailty status of the individual and the patient's willingness to be referred to the Frailty Clinical for further evaluation. functional decline, including age, provenance, drugs, mood, perceived health, history of falls, nutrition, comorbidities, IADL, mobility, continence, feeding and cognitive functions two or more functional domains (physical, cognitive, sensory and nutritive). unintentional weight loss (10 lbs in past year), self-reported exhaustion, weakness (grip strength), slow walking speed, and low physical activity 4 DISCUSSION 4.1 Systematic Review Results Considering that frailty is a common feature of the elderly, it is also important to obtain information on this area. Veninsek and Gabrovec (45) identified four main areas essential for the clinical management of frailty: definition of frailty, epidemiology of frailty, tools for screening and diagnosis frailty and successful interventions for decreasing frailty. The priority objective of the WHO Global Strategy and Action Plan on Aging and Health (13) to fill information gaps at the global level is thus well grounded. This is also confirmed by the results of this systematic review. The international survey conducted by Bruyère et al. (25), which included 44 countries, shows that frailty assessment is becoming a routine daily practice in treating elderly patients. According to this study, 205 (52.8%) clinicians, of whom the majority are geriatric specialists, always assess frailty in their daily practice and 38.1% report measuring it sometimes (25). All international consensus groups recommended all persons older than 70 years should be screened for frailty (22). Bereitgestellt von National & University Library Ljubljana | Heruntergeladen 23.03.20 10 :51 UTC 10.2478/sjph-2019-0012 Zdr Varst. 2019;58(2):91-100 Factors, such as age and malnutrition, increase the risk of frailty (36), but individual deviations may be great, and the level of frailty may vary. Physical frailty in the elderly is a complex condition and the musculoskeletal aging phenotype comprises four key elements: osteoporosis, osteoarthritis, sarcopenia, and frailty (21). On the other hand, measuring the grades of frailty in the elderly can assist in assessment, management, and decision-making for osteoporosis and osteoporotic fractures (19). Fried et al. (44) proposed five frailty criteria: weakness, slow walking speed, low physical activity, self-reported exhaustion, and unintentional weight loss. The majority of physicians (64.9%) generally measure and diagnose frailty using more than one instrument (25). The most widely used tool is the gait speed test, which is performed by 43.8% of physicians (25) and is a simple yet efficient indicator for diagnosing frailty in primary care (17). This is followed by the clinical frailty scale (34.3%), the SPPB test (30.2%), the frailty phenotype test (26.8%), and the frailty index (16.8%) (25). Examples of some commonly used and validated frailty tools include the FRAIL, the Cardiovascular Health Study Frailty Screening Measure, the Clinical Frailty Scale, and the Gerontopole Frailty Screening Tool (22). The Phenotype of Frailty is the most evaluated and frequently-used measure (16). The results of ADVANTAGE JA research (46) showed that there are multiple measurements used to screen and diagnose frailty. They have considered the most relevant, the recommended tools of frailty would be: Clinical Frailty Scale, Edmonton Frailty Scale, FRAIL Index, frailty phenotype, Inter-Frail, Prisma-7, Sherbrooke Postal Questionnaire, Short Physical performance Battery (SPPB), Study of Osteoporotic Fractures Index (SOF) and gait speed. Other researchers (16, 20, 43) report a great variety of frailty scales, but their reliability and validity have rarely been examined (16). Bouillon et al. (16) highlight that only a few studies have evaluated frailty scales in terms of reliability and validity or following specific standards. An acceptable reliability coefficient and predictive validity has been confirmed for the CSHA Clinical Frailty Scale and the Edmonton Frail Scale. The frailty index and the Fried scale have been tested for validity, but not reliability (16). Specific anomalies (terminological and professional anomalies or plagiarism) occur with many assessment scales (16). The majority of studies positively conclude that the scales examined are efficient for identifying the level of frailty (18, 26-28, 31, 32-34, 37, 42). Other studies determine that different instruments result in different estimates of frailty and that the gains in the tests' predictive accuracy are often modest (29, 30). The level of frailty assessed by geriatricians and GPs may differ (23, 24). Among other things, frailty can also be related to self-perceived health (38). Bruyère et al. (25) report that a variety of tools are being used, highlighting the need for standardization and guidelines. None of the assessment scales are used as the gold standard in primary care (18, 27, 34, 42, 43). Widely used scales - a good example of which is the frailty scales developed by Fried et al. (44) - must be based on strict criteria. In addition, improvements and consensus of everyone involved in the healthcare for the elderly are required (16). 4.2 Research Limitations and Strengths Conclusions can be drawn regarding the possible application of existing scales in Slovenia. It would make sense to expand the literature review by including search strings that also identify psychological frailty (e.g. "mental" frailty scales). This is the first review of literature which investigates frailty scales for use at primary level and in terms of reliability and validity. 4.3 Relevance of the Systematic Review Results for the Discipline This systematic review provides insight into which frailty assessments scales are used for the elderly, who assesses frailty of the elderly, and the importance of primary care in assessing elderly people's frailty. 4.4 Potential for Further Research There is a need for more research that assesses the validity, reliability, user-friendliness, comparability, etc., of different frailty scales. 5 CONCLUSION Due to population ageing, there is an increasingly greater need for standardizing the measurement of geriatric frailty using frailty assessment scales. According to the situation (resource constraints) we estimate that the most appropriate scales for primary care in Slovenia are Frailty phenotype (44), Short Physical performance Battery (SPPB) (25) and Edmonton frail scale (25). Implementing such scales in Slovenia requires further research and discussions by leading specialists in this area on extended professional college of doctors of family medicine. Also, nurses from modal practices should be included. Consensus between various healthcare levels should be reached. ACKNOWLEDGEMENTS Special thanks to Prof. Dr. Lijana Zaletel Kragelj, dr. med for mentoring and group of doctoral students of the Interdisciplinary Doctoral Programme in Biomedicine, Bereitgestellt von National & University Library Ljubljana | Heruntergeladen 23.03.20 10 :51 UTC 10.2478/sjph-2019-0012 Zdr Varst. 2019;58(2):91-100 Field Public Health for their suggestions and comments in the process of the final selection of articles. CONFLICTS OF INTEREST The authors declare that no conflicts of interest exist. FUNDING This work was funded by the University of Ljubljana's Faculty of Medicine. 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