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Cited by 9,503Frailty in Older AdultsPharmaceutical Practices and Patient OutcomesNutrition and Health in Aging

Frailty in elderly people

Open access
Clegg, Andrew, Young, John, Iliffe, Steve, Rikkert, Marcel Olde, Rockwood, Kenneth·2013·The Lancet
DOI 10.1016/s0140-6736(12)62167-9PMC PMC4098658
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Abstract

Frailty is the most problematic expression of population ageing. It is a state of vulnerability to poor resolution of homoeostasis after a stressor event and is a consequence of cumulative decline in many physiological systems during a lifetime. This cumulative decline depletes homoeostatic reserves until minor stressor events trigger disproportionate changes in health status. In landmark studies, investigators have developed valid models of frailty and these models have allowed epidemiological investigations that show the association between frailty and adverse health outcomes. We need to develop more efficient methods to detect frailty and measure its severity in routine clinical practice, especially methods that are useful for primary care. Such progress would greatly inform the appropriate selection of elderly people for invasive procedures or drug treatments and would be the basis for a shift in the care of frail elderly people towards more appropriate goal-directed care.

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Crossref · 10.1016/s0140-6736(12)62167-9

Cites

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Claims the paper makes

0 of 179 cited sources checked · 0 supported · 0 flagged

  • Findingcitation

    That study found three or more abnormal systems to be a significant frailty predictor.

    “The presence of abnormal results in three or more systems was a significant predictor of frailty.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [14] Fried, 2009, Nonlinear multisystem physiological dysregulation associated with frailty in older women: implications for etiology and treatment, J Gerontol A Biol Sci Med Sci source

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  • Findingcitation

    A 2009 cross-sectional study of 1,002 women found that the count of abnormal systems among six physiological domains, measured by 12 indicators, related non-linearly to frailty after adjusting for age and comorbidity.

    “A 2009 cross-sectional study involving 1,002 female participants investigated cumulative physiological dysfunction in six different systems (haematological, inflammatory, hormonal, adiposity, neuromuscular and micronutrients) using 12 measures and reported a non-linear relationship between the number of abnormal systems and frailty, independent of age and comorbidity (14).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [14] Fried, 2009, Nonlinear multisystem physiological dysregulation associated with frailty in older women: implications for etiology and treatment, J Gerontol A Biol Sci Med Sci source

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  • Findingcitation

    That study found the total count of abnormal systems predicted frailty better than any single system's abnormalities.

    “Importantly, the number of abnormal systems was more predictive than abnormalities in any particular system.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [14] Fried, 2009, Nonlinear multisystem physiological dysregulation associated with frailty in older women: implications for etiology and treatment, J Gerontol A Biol Sci Med Sci source

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  • Findingcitation

    Two large prospective cohorts have reported an independent link between frailty and dementia.

    “An independent association between frailty and dementia has been reported in two large prospective cohort studies (31, 32).”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [31] Buchman, 2007, Frailty is associated with incident Alzheimer's disease and cognitive decline in the elderly, Psychosom Med source

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    • cites [32] Song, 2011, Nontraditional risk factors combine to predict Alzheimer disease and dementia, Neurology source

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  • Findingcitation

    A cross-sectional study reported lower IGF-1 concentrations in frail individuals than in age-matched controls.

    “One cross-sectional study reported significantly lower levels of IGF-1 in people identified as frail when compared to age-matched controls (36).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [36] Leng, 2004, Serum levels of insulin-like growth factor-I (IGF-I) and dehydroepiandrosterone sulfate (DHEA-S), and their relationships with serum interleukin-6, in the geriatric syndrome of frailty, Aging Clin Exp Res source

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  • Classified as probably not a substantial claim. 13
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    Findingcitation

    The prevalence of frailty among those older than 85 is estimated at 25-50%.

    “It is estimated that a quarter to a half of people over 85 years are frail”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [3] Fried, 2001, Frailty in older adults: evidence for a phenotype, J Gerontol A Biol Sci Med Sci source

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    • cites [4] Song, 2010, Prevalence and 10-year outcomes of frailty in older adults in relation to deficit accumulation, J Am Geriatr Soc source

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  • May combine two claims.

    Findingcitation

    For those over 85, frailty is linked to markedly higher risks of falling, disability, needing long-term care and dying.

    “these people have significantly increased risk of falls, disability, long-term care and death (3, 4)”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [3] Fried, 2001, Frailty in older adults: evidence for a phenotype, J Gerontol A Biol Sci Med Sci source

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    • cites [4] Song, 2010, Prevalence and 10-year outcomes of frailty in older adults in relation to deficit accumulation, J Am Geriatr Soc source

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  • May combine two claims.

    Findingcitation

    A prospective cohort of 273 hospitalised older adults found frailty linked to higher delirium risk (OR 8.5, 95% CI 4.8-14.8) and shorter survival after delirium (median 88 days in frail vs 359 days in non-frail).

    “A prospective cohort study involving 273 hospitalised older people identified that frailty is associated with both increased risk of developing delirium (odds ratio, OR, 8.5, 95% confidence interval, CI, 4.8-14.8) and subsequent reduced survival (median survival in frail older patients with delirium 88 days (95% CI 5-171 days); median survival in non-frail older patients with delirium 359 days (95”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [6] Eeles, 2012, The impact of frailty and delirium on mortality in older inpatients, Age Ageing source

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    Findingcitation

    A cross-sectional study found DHEAS associated with frailty, though confounding by comorbid illness could not be ruled out confidently.

    “A cross-sectional study reported an association between DHEAS and frailty but the influence of comorbid conditions could not be confidently excluded (46).”
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    • cites [46] Voznesensky, 2009, The association between dehydroepiandosterone and frailty in older men and women, Age Ageing source

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    Findingcitation

    In the very old, higher CRP has also been linked to better memory performance.

    “However, higher CRP levels in very old people have also been associated with better memory function (59).”
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    • cites [59] Silverman, 2009, C-reactive protein and memory function suggest antagonistic pleiotropy in very old nondemented subjects, Age Ageing source

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    Findingcitation

    Although frail older adults' muscles seem able to respond to IGF-1, supplementation trials in older people have not shown benefit.

    “although the muscles of frail older people appear to retain the capability to respond to IGF-1 (42) trials of IGF-1 supplementation in older people have failed to demonstrate benefit (43).”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [42] Singh, 1999, Insulin-like growth factor I in skeletal muscle after weight-lifting exercise in frail elders, Am J Physiol

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    • cites [43] Campbell, 2009, Pharmacological treatment of frailty in the elderly, J Pharm Pract Res source

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    Findingcitation

    In that CHS population, 7% were frail, 47% pre-frail and 46% not frail.

    “The population so defined was categorised as 7% frail, 47% pre-frail and 46% not frail.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [3] Fried, 2001, Frailty in older adults: evidence for a phenotype, J Gerontol A Biol Sci Med Sci source

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    Findingcitation

    Frail participants experienced more adverse outcomes than non-frail participants, while pre-frail outcomes fell between the two.

    “People categorised as frail were observed to have more adverse outcomes compared to people categorised as not frail, with the pre-frail group having outcomes intermediate between the two.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [3] Fried, 2001, Frailty in older adults: evidence for a phenotype, J Gerontol A Biol Sci Med Sci source

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    Premisecitation

    Both brain and skeletal muscle possess more cells than are necessary for survival.

    “For example, the brain contains more neurons and skeletal muscle more myocytes than are required for survival (13).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [13] Lipsitz, 2002, Dynamics of stability: the physiologic basis of functional health and frailty, J Gerontol A Biol Sci Med Sci source

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    Premisecitation

    In frailty, physiological reserve declines faster than usual with age, and homeostatic control starts to break down.

    “There is a gradual decline in physiological reserve with ageing but, in frailty, this decline is accelerated and homeostatic mechanisms start failing (8, 9).”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [8] Ferrucci, 2002, Biomarkers of frailty in older persons, J Endocrinol Invest

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    • cites [9] Taffett, 2003, Physiology of aging

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  • Classified as probably not a substantial claim.

    Interpretationnone given

    Frailty arises from cumulative age-related decline across multiple physiological systems, producing vulnerability to sudden health changes after minor stressors.

    “Frailty develops as a consequence of age-related decline in multiple physiological systems, which collectively results in a vulnerability to sudden health status changes triggered by relatively minor stressor events.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Premisecitation

    Frailty involves heightened susceptibility to failed homeostatic recovery after a stressor, and it elevates the likelihood of adverse outcomes including falls, delirium and disability.

    “Frailty is a state of increased vulnerability to poor resolution of homeostasis following a stress, which increases the risk of adverse outcomes including falls, delirium and disability (3, 5, 6).”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites [3] Fried, 2001, Frailty in older adults: evidence for a phenotype, J Gerontol A Biol Sci Med Sci source

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    • cites [5] Walston, 2006, Research agenda for frailty in older adults: toward a better understanding of physiology and etiology: summary from the American Geriatrics Society/National Institute on Aging Research Conference on Frailty in Older Adults, J Am Geriatr Soc source

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    • cites [6] Eeles, 2012, The impact of frailty and delirium on mortality in older inpatients, Age Ageing source

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    Premisecitation

    AGEs have been linked to ageing, chronic illness and death, and they may contribute importantly to frailty.

    “They have been associated with ageing, chronic disease and mortality and may have an important role in frailty (60).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [60] Semba, 2010, Does accumulation of advanced glycation end products contribute to the aging phenotype?, J Gerontol A Biol Sci Med Sci source

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    Premisecitation

    Microglial cells in the ageing brain change structurally and functionally, becoming hyper-responsive to minor stimuli and potentially harming neurons.

    “The ageing brain is also characterised by structural and functional changes to microglial cells, which are the resident immune cell population of the central nervous system (CNS) and are the CNS equivalent of macrophages. They are activated by brain injury and local and systemic inflammation and become primed (hyper-responsive) to small stimuli with ageing, which can potentially cause damage and”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [26] Luo, 2010, Microglia in the aging brain: relevance to neurodegeneration, Mol Neurodegener source

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    • cites [27] Streit, 2006, Microglial senescence: does the brain's immune system have an expiration date?, Trends Neurosci source

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    • cites [28] Cunningham, 2005, Central and systemic endotoxin challenges exacerbate the local inflammatory response and increase neuronal death during chronic neurodegeneration, J Neurosci source

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    Premisecitation

    Frailty has additionally been linked to reduced reserve in respiratory, cardiovascular, renal, blood and clotting systems, with nutrition possibly acting as a mediator.

    “it is important to recognise that frailty has also been associated with loss of physiological reserve in the respiratory (15), cardiovascular (16), renal (17) and haemopoietic and clotting systems (18, 19) and that nutritional status can also be a mediating factor (3, 20-22).”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [15] Vaz Fragoso, 2012, Frailty and respiratory impairment in older persons, Am J Med source

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    • cites [16] Afilalo, 2009, Role of frailty in patients with cardiovascular disease, Am J Cardiol source

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    • cites [17] Abadir, 2011, The frail renin–angiotensin system, Clin Geriatr Med source

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    Interpretationcitation

    Observational data increasingly indicate that frailty precedes and tracks with cognitive impairment and dementia.

    “There is accumulating evidence from observational studies to support a temporal association between frailty, cognitive impairment and dementia.”
    Quote in the paperSubstantial claim

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    Premisecitation

    Most cortical areas lose few individual neurons, yet metabolically demanding cells like hippocampal pyramidal neurons may suffer disproportionately from changes in synapses, protein transport and mitochondria.

    “The loss of individual neurons in the majority of cortical regions is minimal (23), but neurons with high metabolic demands, for example the hippocampal pyramidal neurons, may be disproportionally affected by altered synaptic function, protein transport and mitochondrial function (23).”
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    • cites [23] Bishop, 2010, Neural mechanisms of ageing and cognitive decline, Nature source

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  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    The hypothalamo-pituitary axis connects brain and endocrine function and regulates metabolism and energy through homeostatic hormones.

    “The brain and endocrine system are intrinsically linked through the hypothalamo-pituitary axis, which controls metabolism and energy use via the signaling action of a series of homeostatic hormones (23).”
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    • cites [23] Bishop, 2010, Neural mechanisms of ageing and cognitive decline, Nature source

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    Premisecitation

    The hippocampus plays a central role in cognitive decline and Alzheimer's disease and is crucial to stress responses.

    “The hippocampus has been identified as an important mediator in the pathophysiology of cognitive decline and Alzheimer’s dementia (24) and is a key component of the stress response, sensing increased glucocorticoid levels and relaying information to the hypothalamus in a negative feedback loop (25).”
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    • cites [24] Panegyres, 2004, The contribution of the study of neurodegenerative disorders to the understanding of human memory, QJM source

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    • cites [25] Miller, 2005, Aging, stress and the hippocampus, Ageing Res Rev source

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    Interpretationcitation

    Testosterone levels have been linked to frailty, but this may reflect a sensitive marker rather than a causal mechanism.

    “Although an association between testosterone levels and frailty has been identified (44) this may be a sensitive marker rather than a pathological mechanism (45).”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [44] Cawthon, 2009, Sex hormones and frailty in older men: the osteoporotic fractures in men (MrOS) study, J Clin Endocrinol Metab source

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    • cites [45] Tajar, 2011, Frailty in relation to variations in hormone levels of the hypothalamic-pituitary-testicular axis in older men: results from the European male aging study, J Am Geriatr Soc source

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    Premisecitation

    Advanced glycation end products form when proteins, lipids and nucleic acids are glycated; they can damage cells widely by increasing inflammation.

    “Advanced glycation end products (AGEs) are a group of molecules produced by the glycation of proteins, lipids and nucleic acid that have potential to cause widespread cellular damage by upregulation of inflammation (60).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [60] Semba, 2010, Does accumulation of advanced glycation end products contribute to the aging phenotype?, J Gerontol A Biol Sci Med Sci source

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    Premisecitation

    The brain, endocrine, immune and skeletal muscle systems are closely linked and are the systems most studied so far in frailty.

    “The brain, endocrine system, immune system and skeletal muscle are intrinsically inter-related and are currently the organ systems best studied in the development of frailty (5).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [5] Walston, 2006, Research agenda for frailty in older adults: toward a better understanding of physiology and etiology: summary from the American Geriatrics Society/National Institute on Aging Research Conference on Frailty in Older Adults, J Am Geriatr Soc source

      Not checked in the free run.

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    Premisecitation

    Immune ageing involves fewer stem cells, changed T-cell production, weaker B-cell antibody responses, and less phagocytosis by neutrophils, macrophages and natural killer cells.

    “The ageing immune system is characterised by a decline in stem cells, alterations in T-lymphocyte production, blunting of the B-cell led antibody response and reduced phagocytic activity of neutrophils, macrophages and natural killer cells (50, 51).”
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    • cites [50] Sahin, 2010, Linking functional decline of telomeres, mitochondria and stem cells during ageing, Nature source

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    • cites [51] Miller, 1996, The aging immune system: primer and prospectus, Science source

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    Interpretationcitation

    Frailty is linked to weaker antibody responses to influenza and pneumococcal vaccines, which may explain why vaccination benefits older people only modestly.

    “Furthermore, frailty is associated with an impaired antibody response to influenza (63) and pneumococcal vaccine (64), which helps explain the observation that vaccination in older people is associated with only relatively modest clinical effectiveness (65).”
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    • cites [63] Yao, 2011, Frailty is associated with impairment of vaccine-induced antibody response and increase in post-vaccination influenza infection in community-dwelling older adults, Vaccine source

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    • cites [64] Ridda, 2009, Immunological responses to pneumococcal vaccine in frail older people, Vaccine source

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    • cites [65] Jefferson, 2005, Efficacy and effectiveness of influenza vaccines in elderly people: a systematic review, Lancet source

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    Premisecitation

    The Frailty Index defines frailty using 92 baseline items-symptoms, signs, abnormal labs, diseases and disabilities-referred to as deficits.

    “Ninety-two baseline parameters of symptoms (e.g. low mood), signs (e.g. tremor) and abnormal laboratory values, disease states and disabilities, collectively referred to as deficits, were used to define frailty (75).”
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    • cites [75] Guilley, 2008, Dynamics of frailty and ADL dependence in a five-year longitudinal study of octogenarians, Res Aging source

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    Study design and conductreasoning

    The five phenotype factors were available by chance and came from a cohort not originally designed to study frailty.

    “Additionally, the five factors were fortuitously available and selected from a prospective cohort study that was not designed to investigate frailty.”
    Quote in the paperNot a substantial claim

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    Premisecitation

    Cytokines such as IL-6 and TNFα stimulate muscle breakdown, producing amino acids for energy and releasing antigenic peptides.

    “Inflammatory cytokines including IL-6 and TNFα activate muscle breakdown to generate amino acids for energy and cleave antigenic peptides (69).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [69] Gaczynska, 1994, Peptidase activities of proteasomes are differentially regulated by the major histocompatibility complex-encoded genes for LMP2 and LMP7, Proc Natl Acad Sci USA source

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    Premisecitation

    The Cardiovascular Health Study defined a frailty phenotype by five items: unintentional weight loss, exhaustion, low energy expenditure, slow walking and weak grip.

    “A frailty phenotype was operationalised using a cluster of variables: unintentional weight loss; self-reported exhaustion; low energy expenditure; slow gait speed; weak grip strength (table 2).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [3] Fried, 2001, Frailty in older adults: evidence for a phenotype, J Gerontol A Biol Sci Med Sci source

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  • Classified as probably not a substantial claim.

    Interpretationnone given

    How to translate the phenotype variables reliably into clinical practice remains unclear.

    “However, it is not presently clear how the variables might reliably be translated into clinical practice.”
    Quote in the paperSubstantial claim

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    Interpretationcitation

    This work indicates that a frailty phenotype can be defined and could help detect frailty in routine practice.

    “This work is important as it suggests a frailty phenotype can be defined and might be a basis to detect frailty in routine care.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [3] Fried, 2001, Frailty in older adults: evidence for a phenotype, J Gerontol A Biol Sci Med Sci source

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    Premisenone given

    Normal muscle balance depends on formation of new cells, hypertrophy and protein breakdown, regulated by neural, endocrine and immune systems and affected by diet and activity.

    “Under normal circumstances, muscle homeostasis is maintained in a delicate balance between new muscle cell formation, hypertrophy and protein loss. This delicate balance is coordinated by the brain, endocrine system and immune system and is influenced by nutritional factors and level of physical activity.”
    Quote in the paperNot a substantial claim

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    Premisecitation

    The Frail Elderly Functional Questionnaire (19 items) was identified as a potential outcome measure for frailty intervention studies because it is suitable for telephone or proxy use, valid and reliable, and sensitive to change.

    “The Frail Elderly Functional Questionnaire (19 items) was identified as a potential outcome measure for frailty intervention studies as it is suitable for use by telephone or proxy, valid and reliable (100), and is sensitive to change (101).”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [100] Sternberg, 2011, The identification of frailty: a systematic literature review, J Am Geriatr Soc source

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    • cites [101] Gloth, 1995, Reliability and validity of the Frail Elderly Functional Assessment questionnaire, Am J Phys Med Rehabil source

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    Premisecitation

    Exercise has physiological effects on the brain, endocrine system, immune system and skeletal muscle.

    “Exercise has physiological effects on the brain, endocrine system, immune system and skeletal muscle (42, 117-120).”
    Quote in the paperNot a substantial claim0 of 5 sources checked
    • cites [42] Singh, 1999, Insulin-like growth factor I in skeletal muscle after weight-lifting exercise in frail elders, Am J Physiol

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    • cites [117] Beswick, 2008, Complex interventions to improve physical function and maintain independent living in elderly people: a systematic review and meta-analysis, Lancet source

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    • cites [118] Stuck, 2002, Home visits to prevent nursing home admission and functional decline in elderly people: systematic review and meta-regression analysis, JAMA source

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    • cites [119] van Praag, 2009, Exercise and the brain: something to chew on, Trends Neurosci source

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    • cites [120] Barber, 2012, Is there a role for physical activity in preventing cognitive decline in people with mild cognitive impairment?, Age Ageing source

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    Premisecitation

    Most included studies in that review described primary research to investigate models of frailty or focused on functional restriction, which is insufficient for reliable identification of frailty.

    “most of the included studies described either primary research to investigate models of frailty or the focus was on functional restriction, which, although an important manifestation of frailty, is insufficient for reliable identification of the condition.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [99] de Vries, 2011, Outcome instruments to measure frailty: a systematic review, Ageing Res Rev source

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    Premisecitation

    ACE inhibitors may improve exercise capacity and quality of life.

    “and improve exercise capacity and quality of life (130).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [130] Schaufelberger, 1996, Skeletal muscle changes in patients with chronic heart failure before and after treatment with enalapril, Eur Heart J source

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    Premisecitation

    Meta-analysis found small to moderate effect sizes for exercise on mobility (pooled SMD 0.18, 95% CI 0.05-0.30) and functional ability (pooled SMD 0.27, 95% CI 0.08-0.46).

    “Meta-analysis identified that the effect sizes are likely to be small to moderate (pooled standardised mean difference (SMD) for mobility 0.18, 95% CI 0.05-0.30; pooled SMD for functional ability 0.27, 95% CI 0.08-0.46) (121).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [121] Gleeson, 2006, Exercise and Toll-like receptors, Exerc Immunol Rev

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    Premisecitation

    The Groningen Frailty Indicator and Tilburg Frailty Indicator are simple and similar questionnaire-based approaches to detecting frailty.

    “The Groningen Frailty Indicator (102) and the Tilburg Frailty Indicator (103) are simple and similar (104) questionnaire based approaches to detecting people with frailty.”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [102] Gloth, 1999, The Frail Elderly Functional Assessment questionnaire: its responsiveness and validity in alternative settings, Arch Phys Med Rehabil source

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    • cites [103] Schuurmans, 2004, Old or frail: what tells us more?, J Gerontol A Biol Sci Med Sci source

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    • cites [104] Gobbens, 2012, The predictive validity of the Tilburg Frailty Indicator: disability, health care utilization, and quality of life in a population at risk, Gerontologist source

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    Premisecitation

    Comprehensive geriatric assessment has been applied successfully beyond elderly care medicine.

    “has been applied successfully beyond elderly care medicine (112, 113).”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [112] Rubenstein, 1991, Impacts of geriatric evaluation and management programs on defined outcomes: overview of the evidence, J Am Geriatr Soc source

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    • cites [113] Ellis, 2011, Comprehensive geriatric assessment for older adults admitted to hospital: meta-analysis of randomised controlled trials, BMJ source

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    Premisecitation

    More recent work suggests that the overlap between frailty, comorbidity and disability is more frequent and increases with greater frailty.

    “more recent work suggests that the overlap is more frequent and increases with greater frailty (97).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [97] Fried, 2004, Untangling the concepts of disability, frailty, and comorbidity: implications for improved targeting and care, J Gerontol A Biol Sci Med Sci source

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    Premisecitation

    Slow gait speed successfully characterised the sub-group of older people who had adverse outcomes and had similar accuracy to complex multivariate models that included itemising chronic conditions.

    “Slow gait speed successfully characterised the sub-group of older people who had adverse outcomes and had similar accuracy to complex multivariate models that included itemising chronic conditions.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [107] Syddall, 2003, Is grip strength a useful single marker of frailty?, Age Ageing source

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    Premisecitation

    Frail older people receiving inpatient CGA are more likely to return home, less likely to experience cognitive or functional decline, and have lower in-hospital mortality.

    “Frail older people receiving inpatient CGA are more likely to return home, less likely to experience cognitive or functional decline and have lower in-hospital mortality (111).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [111] Hirdes, 2003, The MDS-CHESS scale: a new measure to predict mortality in institutionalized older people, J Am Geriatr Soc source

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    Premisecitation

    Testosterone improves muscle strength but also increases adverse cardiovascular and respiratory outcomes.

    “Testosterone improves muscle strength but also increases adverse cardiovascular and respiratory outcomes (131).”
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    • cites [131] Onder, 2002, Relation between use of angiotensin-converting enzyme inhibitors and muscle strength and physical function in older women: an observational study, Lancet source

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  • May combine two claims.

    Premisecitation

    The Edmonton Frail Scale is quick to administer (less than 5 minutes) and is valid, reliable and feasible for routine use by non-geriatricians.

    “The Edmonton Frail Scale is a multi-dimensional assessment instrument that includes the TUGT, and a test for cognitive impairment (108). It is quick to administer (less than 5 minutes) and is valid, reliable and feasible for routine use by non-geriatricians”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [108] Studenski, 2011, Gait speed and survival in older adults, JAMA source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing).

    Interpretationcitation

    Physiological measurements to identify older people at risk of frailty may help guide development of earlier preventative interventions.

    “physiological measurements to identify older people at risk of frailty may help guide the development of earlier preventative interventions (85).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [85] Rockwood, 2007, A comparison of two approaches to measuring frailty in elderly people, J Gerontol A Biol Sci Med Sci source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    IGF-1 does not appear to improve muscle strength or bone density in healthy older women.

    “IGF-1 does not appear to improve muscle strength or bone density in healthy older women (132).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [132] Sumukadas, 2007, Effect of perindopril on physical function in elderly people with functional impairment: a randomized controlled trial, CMAJ source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S4 (based). May combine two claims.

    Premisenone given

    Frailty is a state of vulnerability to poor resolution of homeostasis following a stress and is strongly associated with adverse outcomes.

    “It is a state of vulnerability to poor resolution of homeostasis following a stress and is strongly associated with adverse outcomes.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Interpretationreasoning

    An approach using existing clinical data sets, particularly in primary care, would be underpinned by the cumulative deficits frailty model and implies that frailty could be both positively identified and severity graded.

    “This approach would be underpinned by the cumulative deficits frailty model and implies that frailty could be both positively identified and severity graded.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Premisecitation

    The necessary requirements of future frailty instruments, including clinical sensibility, have been defined.

    “The necessary requirements of future frailty instruments, including the important issue of clinical sensibility, have been defined (138).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [138] Avenell, 2009, Vitamin D and vitamin D analogues for preventing fractures associated with involutional and post-menopausal osteoporosis, Cochrane Database Syst Rev source

      Not checked in the free run.

48 of 48

  • The authors state this as an assumption.

    In the cumulative deficit model, every deficit is given the same weight.

    “each of which has an equal weight in mathematical modeling of the FI”

  • The paper relies on this without support.

    The CSHA frailty index is a valid research standard for measuring frailty.

    “the research standard CSHA FI”

  • The paper relies on this without support.

    The phenotype model and the cumulative deficit model are conceptually different models of frailty.

    “two conceptually different models of frailty”

  • The paper relies on this without support.

    Most frailty models were developed in Caucasian populations.

    “Most frailty models were developed in Caucasian populations”
4 of 4

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Overlap percentage exceeds the reported frailty prevalence

    Minor

    The paper says 7% of the CHS population was frail, but later says 46.2% of that population had both frailty and comorbidity. A subgroup with frailty cannot be larger than the entire frail group.

1 of 1

Cites

Flagged first, then by citations

Research works printed but not linked: 2

  1. Kinsella, 2005, vol. 60
  2. Rockwood, 2004, Prevalence, attributes, and outcomes of fitness and frailty in community-dwelling older adults: report from the Canadian study of health and aging, J Gerontol A Biol Sci Med Sci, 59, 1310, 10.1093/gerona/59.12.1310 · DOI · Paper page

Cited by

Sorted by citations

Related

Authors
Clegg, A., Young, J., Iliffe, S., Rikkert, M. O., & Rockwood, K.
Affiliations
  • University of Leeds (GB)
  • University College London (GB)
  • Dalhousie University (CA)
Corresponding author
Clegg, Andrew
ORCID
Venue
The Lancet
Publisher
Elsevier BV
Published
2013-03
Volume
381
Issue
9868
Pages
752-762
ISSN
  • 0099-5355 (ISSN-L)
  • 0140-6736
DOI
10.1016/s0140-6736(12)62167-9
PMC
PMC4098658
OpenAlex
W2142514031
Cited by
9,503
References
142
Citations by year
2026: 1008 · 2025: 982 · 2024: 1124 · 2023: 915 · 2022: 961 · 2021: 892 · 2020: 883 · 2019: 695 · 2018: 583 · 2017: 509 · 2016: 367 · 2015: 319 · 2014: 185 · 2013: 66
FWCI
29.58
Type
journal article
Language
en
Open access
Licence
www.elsevier.com/tdm/userlicense/1.0/ (tdm)
Locations
  • The Lancet (publishedVersion)
  • PubMed (publishedVersion)
  • Europe PMC (PubMed Central) (acceptedVersion)
  • PubMed Central (acceptedVersion)
  • UCL Discovery (University College London) (submittedVersion)
  • Radboud Repository (Radboud University) (submittedVersion)
Funders
University of Leeds
Topics
  • Health Sciences › Medicine › Geriatrics and Gerontology › Frailty in Older Adults
  • Health Sciences › Medicine › Geriatrics and Gerontology › Pharmaceutical Practices and Patient Outcomes
  • Health Sciences › Medicine › Physiology › Nutrition and Health in Aging
Keywords
frailty, older adults, population aging, frailty models, frailty detection, primary care
MeSH terms
Aged, Aged, 80 and over, Aging, Brain, Endocrine System, Female, Health Services for the Aged, Humans, Immune System, Male, Models, Biological, Geriatric Assessment, Frail Elderly

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read under definition version 3 (extract-v3) on 2026-09-28.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-09-28.

Statistics and arithmetic are recomputed, not judged.

Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.

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