Frailty instruments show weak agreement raising clinical concern for patients on dialysis
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While all the assessed instruments demonstrated a high prevalence of frailty in patients receiving hemodialysis, researchers from the United Kingdom found a 21.5% difference in frailty prevalence between the lowest and highest estimations.
Thus, Benjamin Anderson, MBChB, of the department of nephrology and transplantation at Queen Elizabeth Hospital in Birmingham, and colleagues suggested that challenges may arise when making clinical decisions based on frailty scores.
Frailty, clinical decision-making
“Our data demonstrated weakest agreement between frailty instruments in the vulnerable category. This is of particular concern as this is the ‘decision zone’ where clinical conclusions may be drawn based upon whether a patient is frail or not-frail (ie, vulnerable), which may lead to detrimental consequences for [hemodialysis] HD recipients. Discrepancy between estimated frailty prevalence and agreement between instruments demonstrates the difficulties in attempting to divide frailty into neat ‘silos’ and is in keeping with a syndrome which defies easy clinical – and indeed mechanistic – definition. The weak agreement between instruments on frailty classification suggests caution be applied when attempting to dichotomize individual patients into frailty groups.”
For the Frailty Intervention Trial in End-Stage Patients on Hemodialysis (FITNESS)
study, patients who had been on hemodialysis for at least 3 months and had no hospital admissions for dialysis access within 4 weeks were recruited (n = 485; median age was 63 years; 42.1% were of “non-white ethnicity”). Frailty prevalence was compared utilizing four instruments: the frailty index (FI), frailty phenotype (FP), Edmonton frailty scale (EFS) and clinical frailty scale (CFS).
“To the best of our knowledge, this study is the first to directly compare commonly used frailty instruments in a large prevalent hemodialysis cohort,” the researchers wrote. “One of its major strengths is study recruitment representative of the local cohort, featuring a diverse mix of demographics, comorbidities and socioeconomic backgrounds. This should provide reassurance for translation of these findings to clinical application in real-world cohorts.”
Frailty prevalence, variations by instrument
Results indicated a high prevalence of frailty regardless of the instrument used, with 41.9% of patients categorized as frail by the frailty phenotype, 50.2% by the Edmonton frailty scale, 53.8% by the clinical frailty scale and 63.3% by the frailty index. Although women were more likely to have frailty, researchers observed no association between frailty and age or ethnicity.
Researchers noted strong correlation between instruments, but intraclass correlation coefficient for frailty agreement was 0.628 and only weak agreement was found between instrument pairs. Further, agreement between frailty instruments was weakest the vulnerable category.
“Our data, highlighting significant variability between different measures, reinforces the importance of achieving consensus on this issue. However, the optimal instrument requires a balance between ease of use, utility and predictive value for adverse outcomes,” Anderson and colleagues concluded. “Prospective monitoring of the FITNESS cohort, with record linkage to clinical outcomes, will provide further insight into the clinical sequelae associated with different frailty instruments and aid such discussions to achieve consensus.”
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