History of the Edmonton Frail Scale
Development of the Edmonton Frail Scale (EFS) started at the University of Alberta in 1999 by Dr. Darryl Rolfson. It has been used for both research and clinical purposes since then. The EFS was first presented for peer review at the Canadian Geriatric Society in Edmonton in 2000 [1]. Since its validation and reliability was published in 2006 [2], the EFS has been increasingly used for research, educational, and clinical purposes worldwide.
Delirium after Heart Surgery
In 1996, Dr. Rolfson, then a senior resident in Internal Medicine, was interested in complications after elective heart surgery in older adults. He found that delirium was present in about one third of the cases. Also, there was an eight-fold risk of delirium for those who had a previous stroke. Further, the risk of delirium doubled for every additional 20 minutes of cardiopulmonary bypass (CPB) during surgery [3]. This challenged the notion that chronological age was the primary factor in the decision to proceed with heart surgery. If age was less important, then what makes an individual more likely to experience delirium and other adverse outcomes after heart surgery?
How Delirium and Frailty are related
Delirium was increasingly seen as a common presentation of illness, caused by the pre-existing health status and new health-related stress [4]. Delirium was seen as an atypical presentation of illness [5] because other symptoms were expected for common acute illnesses, such as infections, acute organ-related illness or medication related side effects. Examples of other “atypical presentations of illness”, or “acute geriatric syndromes”, were immobility, falls, urinary incontinence, dehydration, nutritional crisis. What did these patterns have in common? First, the list of acute illnesses that caused each pattern was very similar. Second, the particular pattern was a hint to underlying systems of vulnerability. This exaggerated vulnerability is a state that we now call “frailty”, and it is manifest as a multidimensional syndrome. In this way, frailty, much more than age, became a powerful way to stratify risk of adverse outcomes under stress, and to anticipate who might manifest illness in atypical ways (ie. delirium, immobility, and other presentations of illness).
Frailty Models
In 1998, Dr. Rolfson was in his final year of subspecialty training in Geriatric Medicine, at the University of Alberta, in Edmonton, Alberta, Canada. He conducted a literature review of frailty, and from that constructed four emerging conceptual models as follows:
Physical Frailty – “Sarcopenia” - a physical decline with inactivity and weight loss.
Physiological Frailty – “Homeostenosis” - a loss of physiologic reserve capacity resulting in vulnerability
Frailty as Disability – a functional decline characterized by dependence in activities of daily living
Dynamic Frailty – A precarious state. Considering all that is known about this person, and their resources, future independence “hangs in the balance”.
Geriatrician’s Clinical Impression of Frailty
Because there was, at the time, no gold standard for frailty, the opinion of a geriatrician, after comprehensive geriatric assessment (CGA), was selected as the best criterion standard. Based on the literature synthesis, a new measure later named the “Geriatrician’s Clinical Impression of Frailty” (GCIF) was created. The GCIF was then reviewed by an expert panel of eight specialist geriatricians who found that it faithfully encompassed all four definitions of frailty, and their own concept of frailty, with minimal redundancy in a relatively easy format. After further adjustments, the 35 point GCIF was finalized. Briefly, the form comprised [3] contributors to frailty (one point for each of nine geriatric syndromes that threaten independence in six months), [4] manifestations of acute illness or stressors (one point for each of six atypical disease presentations) and [5] the specialist’s own impression of frailty (ranked 1-5 points) applied to each of the four definitions.
Constructing the Edmonton Frail Scale
There were initially seven domains of frailty to be included in a frailty checklist. These included cognition, general health status, functional independence, social support, medication, use, mood, and physical frailty. Candidate items to represent these domains were then selected, as much as possible, to reflect existing validated simple screening questions. Based on peer review at the Canadian Geriatric Society meeting in 1998, physical frailty was removed, and items on nutrition and urinary incontinence were added. A multidisciplinary expert panel that included two older adults then reviewed the draft EFS for feedback on its purpose, framework, clarity of instructions, content, item redundancy, and scoring. Advice was given on who should administer the scale, estimated administration time, and the need for special training. With the addition of functional performance as a ninth domain, and decisions on the weighting of each domain, the content and weighting of the EFS was essentially complete.
The Development and Validation of the EFS was presented as a Podium presentation at the Canadian Geriatric Society Meeting in Edmonton, Alberta in 2000. The Development of the GCIF was presented as a poster at the International Association of Gerontology Meeting in Vancouver in 2001. The published manuscript on the Development and Validation of the Edmonton Frail Scale was subsequently published in 2006 [6].
Development of the Edmonton Frail Scale-Acute Care (EFS-AC)
With the worldwide COVID 19 pandemic in March 2020, there was a rapid need to offer a version of the Edmonton Frail Scale that could be administered virtually and in acute care settings. The Bedside version includes two items that are based on performance in the domains of cognition and functional performance. In 2009, Hilmer et al had developed a replacement item for functional performance, and in 2018, Rose et al had developed a replacement item for cognition [7,8]. Both items were independently validated. The EFS-AC adds to the EFS by emphasizing the baseline frailty status rather than the current frailty status in acute care settings. This is helpful since performance during acute illness may change from the baseline status and the anticipated status after recovery. This same modification is helpful when the assessment must be done virtually, over a telephone or videoconference encounter. The validity of the EFS-AC needs to be further tested in these settings.
References
Rolfson DB, Majumdar SR, Taher A, Tsuyuki RT. Development and validation of a new instrument for frailty. Clin Invest Med 2000; 23: 336. Podium presentation at a plenary session at the Annual Meeting of the Canadian Geriatrics Society, Edmonton AB, Oct. 28-30, 2000.
Rolfson DB, Majumdar SR, Tsuyuki RT, Tahir A, Rockwood K. Validity and Reliability of the Edmonton Frail Scale. Age and Ageing 2006 Sep;35(5):526-9.
Rolfson, D.B., et al., Incidence and risk factors for delirium and other adverse outcomes in older adults after coronary artery bypass graft surgery. Can J Cardiol, 1999. 15(7): p. 771-6.
Inouye, S.K., Delirium in older persons. N Engl J Med, 2006. 354(11): p. 1157-65.
Jarrett, P.G., et al., Illness presentation in elderly patients. Arch Intern Med, 1995. 155(10): p. 1060-4.
Rolfson, D.B., et al., Validity and reliability of the Edmonton Frail Scale. Age Ageing, 2006. 35(5): p. 526-9.
Hilmer SN, Perera V, Mitchell S, Murnion BP, Dent J, Bjoreck B, Matthews S, Rolfson DB, The assessment of frailty in older people in acute care. Australas J Ageing. 2009 Dec;28(4):182-8.
Rose M, Yang A, Welz M, Masik A, Staples, M. Novel modification of the Reported Edmonton Frail Scale. Australa J Ageing 2018Dec;37(4):305-308. doi: 10.1111/ajag.12533