Heart, Lung and Circulation
Original Article| Volume 31, ISSUE 9, P1241-1246, September 2022

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Clinician Estimates of Frailty Compared to Formal Frailty Assessment in Adults With Heart Failure: A Cross-Sectional Analysis

Published:April 29, 2022DOI:


      Frailty assessment is recommended for patients with heart failure. Despite the availability of instruments to assess frailty, there are no clear recommendations regarding the optimal instrument to use in a heart failure context. This ambiguity combined with a lack of education and resources, often leads clinicians to rely on subjective estimates of frailty, such as ‘the end-of-the-bed’ or ‘eyeball’ test.


      To examine the association between clinician-estimated frailty and formal frailty assessment in adults with heart failure.


      Cross-sectional analysis of the FRAilty MEasurement in Heart Failure (FRAME-HF) study. Participants: (1) Adults aged ≥18 years in the outpatient heart failure clinic and cardiology ward; (2) and cardiovascular clinicians (nurses, physicians, and allied-health professionals). Following participant recruitment, cardiovascular clinicians were asked to rate the participant’s frailty status based on their routine clinical assessment as either: frail, pre-frail, or non-frail, which was then compared to a formal frailty assessment using a modified version of the Frailty Phenotype. The association between clinician-estimated frailty and formal frailty assessment were examined using a weighted Kappa statistic and Spearman’s correlation coefficient.


      A total of 75 patients and 39 clinicians were recruited, producing 194 paired frailty assessments. Mean age of the patients was 54 (±13) years. Correlation of pooled clinician-estimated frailty to formal frailty was fair (0.52, p=0.00). Correlation was highest between allied-health estimated frailty and formal frailty (0.70, p=0.00). Agreement between pooled clinician-estimated frailty and formal frailty was fair (0.33) and was highest between allied health-estimated frailty and formal frailty (0.45).


      Subjective clinician-estimated frailty is not a reliable replacement for formal frailty assessment in adults with heart failure, underscoring the need for assessment using a valid and reliable instrument.


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        • Yang X.
        • Lupón J.
        • Vidán Maria T.
        • Ferguson C.
        • Gastelurrutia P.
        • Newton Phillip J.
        • et al.
        Impact of frailty on mortality and hospitalization in chronic heart failure: a systematic review and meta-analysis.
        J Am Heart Assoc. 2018; 7e008251
        • Uchmanowicz I.
        • Lee C.S.
        • Vitale C.
        • Manulik S.
        • Denfeld Q.E.
        • Uchmanowicz B.
        • et al.
        Frailty and the risk of all-cause mortality and hospitalization in chronic heart failure: a meta-analysis.
        ESC Heart Fail. 2020; 7: 3427-3437
        • McDonagh J.
        • Martin L.
        • Ferguson C.
        • Jha S.R.
        • Macdonald P.S.
        • Davidson P.M.
        • et al.
        Frailty assessment instruments in heart failure: a systematic review.
        Eur J Cardiovasc Nurs. 2017; 17: 23-35
        • Fried L.
        • Tangen C.
        • Walston J.
        • Newman A.
        • Hirsch C.
        • Gottdiener J.
        Frailty in older adults: evidence for a phenotype.
        J Gerontol A Biol Sci Med Sci. 2001; 56: M146-M156
        • Buta B.J.
        • Walston J.D.
        • Godino J.G.
        • Park M.
        • Kalyani R.R.
        • Xue Q.L.
        • et al.
        Frailty assessment instruments: systematic characterization of the uses and contexts of highly-cited instruments.
        Ageing Res Rev. 2015; 26: 53-61
        • Vitale C.
        • Jankowska E.
        • Hill L.
        • Piepoli M.
        • Doehner W.
        • Anker S.D.
        • et al.
        Heart Failure Association of the European Society of Cardiology position paper on frailty in patients with heart failure.
        Eur J Heart Fail. 2019; 21: 1299-1305
        • Mitnitski A.B.
        • Mogilner A.J.
        • Rockwood K.
        Accumulation of deficits as a proxy measure of aging.
        ScientificWorldJournal. 2001; 1
        • Rockwood K.
        • Mitnitski A.
        Frailty in relation to the accumulation of deficits.
        J Gerontol A Biol Sci Med Sci. 2007; 62: 722-727
        • Atherton J.J.
        • Sindone A.
        • De Pasquale C.G.
        • Driscoll A.
        • MacDonald P.S.
        • Hopper I.
        • et al.
        National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand: Guidelines for the Prevention, Detection, and Management of Heart Failure in Australia 2018.
        Heart Lung Circ. 2018; 27: 1123-1208
        • Ponikowski P.
        • Voors A.A.
        • Anker S.D.
        • Bueno H.
        • Cleland J.G.F.
        • Coats A.J.S.
        • et al.
        2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure of the European Society of Cardiology (ESC). Developed with the special contribution of the Heart Failure Association (HFA) of the ESC.
        Eur Heart J. 2016; 37: 2129-2200
        • Dent E.
        • Lien C.
        • Lim W.S.
        • Wong W.C.
        • Wong C.H.
        • Ng T.P.
        • et al.
        The Asia-Pacific Clinical Practice Guidelines for the Management of Frailty.
        J Am Med Dir Assoc. 2017; 18: 564-575
        • Dent E.
        • Kowal P.
        • Hoogendijk E.O.
        Frailty measurement in research and clinical practice: A review.
        Eur J Intern Med. 2016; 31: 3-10
        • Vitale C.
        • Hill L.
        Assess frailty but avoid frailtyism.
        Eur Heart J Suppl. 2019; 21: L17-L19
        • Afilalo J.
        • Alexander K.P.
        • Mack M.J.
        • Maurer M.S.
        • Green P.
        • Allen L.A.
        • et al.
        Frailty assessment in the cardiovascular care of older adults.
        J Am Coll Cardiol. 2014; 63: 747-762
        • Hii T.B.
        • Lainchbury J.G.
        • Bridgman P.G.
        Frailty in acute cardiology: comparison of a quick clinical assessment against a validated frailty assessment tool.
        Heart Lung Circ. 2015; 24: 551-556
        • Jain R.
        • Duval S.
        • Adabag S.
        How accurate is the eyeball test?.
        Circ Cardiovasc Qual Outcomes. 2014; 7: 151-156
        • Wleklik M.
        • Uchmanowicz I.
        • Jankowska E.A.
        • Vitale C.
        • Lisiak M.
        • Drozd M.
        • et al.
        Multidimensional approach to frailty.
        Front Psych. 2020; 11: 564
        • Kobashigawa J.
        • Shah P.
        • Joseph S.
        • Olymbios M.
        • Bhat G.
        • Dhital K.
        • et al.
        Frailty in heart transplantation: report from the heart workgroup of a consensus conference on frailty.
        Am J Transplant. 2020;
        • McDonagh J.
        • Salamonson Y.
        • Ferguson C.
        • Prichard R.
        • Jha S.R.
        • Macdonald P.S.
        • et al.
        Evaluating the convergent and discriminant validity of three versions of the frailty phenotype in heart failure: results from the FRAME-HF study.
        Eur J Cardiovasc Nurs. 2019; 19: 55-63
        • World Medical A.
        World medical association declaration of Helsinki: ethical principles for medical research involving human subjects.
        J Am Med Dir Assoc. 2013; 310: 2191-2194
        • Jha S.R.
        • Hannu M.K.
        • Chang S.
        • Montgomery E.
        • Harkess M.
        • Wilhelm K.
        • et al.
        The prevalence and prognostic significance of frailty in patients with advanced heart failure referred for heart transplantation.
        Transplantation. 2016; 100: 429-436
        • Aili S.R.
        • De Silva R.
        • Wilhelm K.
        • Jha S.R.
        • Fritis-Lamora R.
        • Montgomery E.
        • et al.
        Validation of cognitive impairment in combination with physical frailty as a predictor of mortality in patients with advanced heart failure referred for heart transplantation.
        Transplantation. 2022; 106: 200-209
        • Montgomery E.
        • Macdonald P.
        • Newton P.
        • Jha S.
        • Hannu M.
        • Thomson C.
        • et al.
        Reversibility of frailty after lung transplantation.
        J Heart Lung Transplant. 2020; 37: S249
        • Montgomery E.
        • Macdonald P.S.
        • Newton P.J.
        • Chang S.
        • Jha S.R.
        • Hannu M.K.
        • et al.
        Frailty as a predictor of mortality in patients with interstitial lung disease referred for lung transplantation.
        Transplantation. 2020; 104: 864-872
        • Akoglu H.
        User's guide to correlation coefficients.
        Turk J Emerg Med. 2018; 18: 91-93
        • Fleiss J.
        • Levin B.
        • Cho Paik M.
        Statistical Methods for Rates and Proportions.
        Third Edition. John Wiley & Sons, Inc., 2003
        • Salter M.L.
        • Gupta N.
        • Massie A.B.
        • McAdams-DeMarco M.A.
        • Law A.H.
        • Jacob R.L.
        • et al.
        Perceived frailty and measured frailty among adults undergoing hemodialysis: a cross-sectional analysis.
        BMC Geriatrics. 2015; 15: 52
        • van der Vorst A.
        • Zijlstra G.A.R.
        • De Witte N.
        • De Lepeleire J.
        • Kempen G.I.J.M.
        • Schols J.M.G.A.
        • et al.
        Can proxy assessments serve as a first screener for identifying people at risk for multidimensional frailty?.
        Eur Geriatr Med. 2018; 9: 501-507
        • Hubbard R.E.
        • Story D.A.
        Does frailty lie in the eyes of the beholder?.
        Heart Lung Circ. 2015; 24: 525-526
        • Yanagawa B.
        • Graham M.M.
        • Afilalo J.
        • Hassan A.
        • Arora R.C.
        Frailty as a risk predictor in cardiac surgery: beyond the eyeball test.
        J Thorac Cardiovasc Surg. 2018; 156: 172-176.e2
        • Miller-Davis C.
        • Marden S.
        • Leidy N.K.
        The New York Heart Association classes and functional status: what are we really measuring?.
        Heart Lung. 2006; 35 (217–24 8p)
        • McDonagh J.
        • Ferguson C.
        • Newton P.J.
        Frailty Assessment in heart failure: an overview of the multi-domain approach.
        Curr Heart Fail Rep. 2018; 15: 17-23