Predictive validity of the Brazilian version of the Tilburg Frailty Indicator for adverse health outcomes in older adults

Highlights

• The validation of Brazilian version of the TFI is now complete.

• TFI is a good predictor of adverse health outcomes among users of primary health care.

• Health care professionals in Brazil can use the TFI for the evaluation of frailty in elderly people.

Abstract

Purpose

This study aimed to determine the predictive value of the Brazilian Tilburg Frailty Indicator (TFI) for adverse health outcomes (falls, hospitalization, disability and death), in a follow-up period of twelve months.

Methods

This longitudinal study was carried out with a sample of people using primary health care services in Rio de Janeiro, Brazil. At baseline the sample consisted of 963 people aged 60 years and older. A subset of all respondents participated again one year later (n = 640, 66.6% response rate). We used the TFI, the Katz’s scale for assessing ADL disability and the Lawton Scale for assessing IADL disability. Falls, hospitalization and death were also assessed using a questionnaire.

Results

The prevalence of frailty was 44.2% and the mean score of the TFI was 4.4 (SD = 3.0). There was a higher risk of loss in functional capacity in ADL (OR = 3.03, CI95% 1.45–6.29) and in IADL (OR = 1.51, CI95% 1.05–2.17), falls (OR = 2.08, CI95% 1.21–3.58), hospitalization (OR = 1.83, CI95% 1.10–3.06), and death (HR = 2.73, CI95% 1.04–7.19) for frail when compared to non-frail elderly, in the bivariate analyses. Controlling for the sociodemographic variables, the frailty domains together improved the prediction of hospitalization, falls and loss in functional capacity in ADL, but not loss in functional capacity in IADL.

Conclusion

The TFI is a good predictor of adverse health outcomes among elderly users of primary care services in Brazil and appears an adequate and easy to administer tool for monitoring their health conditions.

Introduction

The model of health care for the elderly that predominates in Brazil still prioritizes both treatment of chronic problems already installed and treatment effects, which generates great use of services and is inefficient and expensive (Marin et al., 2008). It is pointed out that there is a need for changes in the methodologies for providing health care to elderly populations, which consider the importance of maintaining functional independence, quality of life and social insertion of individuals (Lima-Costa & Veras, 2003). In this context, it is important to evaluate frailty among Brazilian older adults, especially in users of primary health care.

Frailty is recognized as a geriatric syndrome and considered as “a state that affects individuals experiencing losses in one or more domains of human functioning, caused by the influence of a number of variables and increasing the risk of adverse health outcomes” (Gobbens, Luijkx, Wijnen-Sponselee, & Schols, 2010). Frailty predicts disability and death, as well as other undesirable outcomes such as falls, fractures, hospitalization and greater use of health services (Fried et al., 2001; Gobbens & van Assen, 2012; Samper-Ternent, Karmarkar, Graham, Reistetter, & Ottenbacher, 2012). In a systematic review aimed at comparing the prevalence of frailty among community-dwelling elderly according to sex, age and definition of frailty, a variation of 4.0–59.1% was identified among the 21 selected studies (mean prevalence = 10.7%; 95% CI 10.5–10.9), with the highest frequencies observed in studies using multidimensional frailty assessment instruments (Collard, Boter, Schoevers, & Voshaar, 2012). In addition to the high prevalence in elderly populations and the increased risk for adverse outcomes, frailty is considered a condition with great potential for reversibility, which makes it an important condition for monitoring elderly health in clinical practice (Rodriguez-Mañas & Fried, 2015).

In the last 20 years, different instruments have been proposed for the evaluation of frailty in the elderly. Mostly, they were based on two different approaches: unidimensional, which evaluates only issues related to physical health (Ensrud et al., 2008; Fried et al., 2001; Hyde et al., 2010; Peterson et al., 2009), and a multidimensional that also evaluates other areas of health such as psychological and social health (Cacciatore et al., 2005; Frieswijk, Buunk, Steverink, & Slaets, 2004; Gobbens, Luijkx et al., 2010; Puts, Lips, & Deeg, 2005; Rockwood et al., 1999; Strawbridge, Shema, Balfour, Higby, & Kaplan, 1998). Believing that the multidimensional approach is most adequate to the current setting of frailty in Brazil, the Tilburg Frailty Indicator (TFI) was identified as an appropriate instrument to identify this condition, since, in addition to aggregation of other areas besides physical health, it does not include variables considered as outcomes of frailty, such as disability, falls and hospitalization (Santiago, Luz, Mattos, & Gobbens, 2012). Moreover, a recent systematic review concluded the TFI has the most robust evidence of reliability and validity among 38 multicomponent frailty assessment instruments (Sutton et al., 2016).

The TFI is an instrument for assessing frailty in the elderly that was developed in the Netherlands, and evaluates the physical, psychological and social domains of health. It can be applied by any health professional and requires little financial resources and little time for application (Gobbens, van Assen, Luijkx, Wijnen-Sponselee, & Schols, 2010a). The process of cross-cultural adaptation of the TFI to the Brazilian elderly population has already been carried out, as well as the stages of evaluation of the conceptual, item, semantic and operational equivalences and the pre-test of the instrument version, and the evaluation of its statistical properties (Santiago et al., 2012, Santiago, Luz, Mattos, Gobbens, & van Assen, 2013). Based on the results of previous studies, it is believed that the Brazilian version of the instrument is a useful and valid tool for the evaluation of frailty in the country.

The ability to predict adverse health outcomes, especially disability, is highlighted as one of the main virtues of the evaluation of frailty in the clinical practice of geriatrics and gerontology. Its inclusion in the routine of primary health care has also been valued, with a view to early intervention, reversibility of the condition, prevention of potential damages to the quality of life of elderly, and reduction of costs for the health system (De Lepeleire, Iliffe, Mann, & Degryse, 2009; Lacas & Rockwood, 2012).

Some studies have been conducted aimed at determining the predictive value of the TFI in a longitudinal study. According to Gobbens et al., 2012, Gobbens et al., 2014 the TFI is a valid instrument to predict disability, health care utilization and quality of life in Dutch community-dwelling elderly. It was concluded that assessment by the TFI is sufficient for predicting health care utilization, but for predicting disability the use of both the TFI and the Timed Up & Go test was recommended.

In addition, Coelho, Paúl, Gobbens, and Fernandes (2015) concluded that the TFI is a predictor of disability and quality of life in Portuguese elderly and Mulasso, Roppolo, Gobbens, and Rabaglietti (2016) showed that the TFI was predictive for falls at 12 months in an Italian aged population. Finally, van Campen (2011) demonstrated that frailty assessed with the TFI is a predictor for death, after adjusting for age, gender and educational level.

All aforementioned TFI-studies have been conducted in European countries. This study aims to evaluate frailty assessed by the Brazilian TFI as a predictor of falls, hospitalizations, functional incapacity and death in elderly, during a one-year follow-up period, in a Latin American country.