Adverse outcomes of frailty in the elderly: the Rotterdam Study


To investigate the prevalence of frailty in a Dutch elderly population and to identify adverse health outcomes associated with the frailty phenotype independent of the comorbidities. Cross-sectional and longitudinal analyses within the Rotterdam Study (the Netherlands), a prospective population-based cohort study in persons aged ≥55 years. Frailty was defined as meeting three or more of five established criteria for frailty, evaluating nutritional status, physical activity, mobility, grip strength and exhaustion. Intermediate frailty was defined as meeting one or two frailty criteria. Comorbidities were objectively measured. Health outcomes were assessed by means of questionnaires, physical examinations and continuous follow-up through general practitioners and municipal health authorities for mortality. Of 2,833 participants (median age 74.0 years, inter quartile range 9) with sufficiently evaluated frailty criteria, 163 (5.8 %) participants were frail and 1,454 (51.3 %) intermediate frail. Frail elderly were more likely to be older and female, to have an impaired quality of life and to have fallen or to have been hospitalized. 108 (72.0 %) frail participants had ≥2 comorbidities, compared to 777 (54.4 %) intermediate frail and 522 (44.8 %) non-frail participants. Adjusted for age, sex and comorbidities, frail elderly had a significantly increased risk of dying within 3 years (HR 3.4; 95 % CI 1.9–6.4), compared to the non-frail elderly. This study in a general Dutch population of community-dwelling elderly able to perform the frailty tests, demonstrates that frailty is common and that frail elderly are at increased risk of death independent of comorbidities.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2
Fig. 3



Body mass index


Center for epidemiological studies depression


Confidence interval


Chronic obstructive pulmonary disease

FEV1 :

Forced expiratory volume in 1 s


Forced vital capacity




Hazard ratio


Inter quartile range


Odds ratio


Quality of life


Rotterdam Study


White blood cells


  1. 1.

    Mitnitski AB, Graham JE, Mogilner AJ, et al. Frailty, fitness and late-life mortality in relation to chronological and biological age. BMC Geriatr. 2002;2:1.

    PubMed Central  PubMed  Article  Google Scholar 

  2. 2.

    Collard RM, Boter H, Schoevers RA, et al. Prevalence of frailty in community-dwelling older persons: a systematic review. J Am Geriatr Soc. 2012;60(8):1487–92.

    PubMed  Article  Google Scholar 

  3. 3.

    Clegg A, Young J, Iliffe S, et al. Frailty in elderly people. Lancet. 2013;381(9868):752–62.

    PubMed  Article  Google Scholar 

  4. 4.

    Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol Ser A Biol Sci Med Sci. 2001;56(3):M146–56.

    CAS  Article  Google Scholar 

  5. 5.

    Rockwood K, Stadnyk K, MacKnight C, et al. A brief clinical instrument to classify frailty in elderly people. Lancet. 1999;353(9148):205–6.

    CAS  PubMed  Article  Google Scholar 

  6. 6.

    Puts MT, Lips P, Deeg DJ. Sex differences in the risk of frailty for mortality independent of disability and chronic diseases. J Am Geriatr Soc. 2005;53(1):40–7.

    PubMed  Article  Google Scholar 

  7. 7.

    Ensrud KE, Ewing SK, Cawthon PM, et al. A comparison of frailty indexes for the prediction of falls, disability, fractures, and mortality in older men. J Am Geriatr Soc. 2009;57(3):492–8.

    PubMed Central  PubMed  Article  Google Scholar 

  8. 8.

    Ensrud KE, Ewing SK, Taylor BC, et al. Comparison of 2 frailty indexes for prediction of falls, disability, fractures, and death in older women. Arch Intern Med. 2008;168(4):382–9.

    PubMed  Article  Google Scholar 

  9. 9.

    Bouillon K, Kivimaki M, Hamer M, et al. Measures of frailty in population-based studies: an overview. BMC Geriatr. 2013;13:64.

    PubMed Central  PubMed  Article  Google Scholar 

  10. 10.

    Fried LP, Ferrucci L, Darer J, et al. Untangling the concepts of disability, frailty, and comorbidity: implications for improved targeting and care. J Gerontol Ser A Biol Sci Med Sci. 2004;59(3):255–63.

    Article  Google Scholar 

  11. 11.

    Cawthon PM, Marshall LM, Michael Y, et al. Frailty in older men: prevalence, progression, and relationship with mortality. J Am Geriatr Soc. 2007;55(8):1216–23.

    PubMed  Article  Google Scholar 

  12. 12.

    Sternberg SA, Wershof Schwartz A, Karunananthan S, et al. The identification of frailty: a systematic literature review. J Am Geriatr Soc. 2011;59(11):2129–38.

    PubMed  Article  Google Scholar 

  13. 13.

    Hofman A, van Duijn CM, Franco OH, et al. The Rotterdam Study: 2012 objectives and design update. Eur J Epidemiol. 2011;26(8):657–86.

    PubMed Central  PubMed  Article  Google Scholar 

  14. 14.

    Hofman A, Grobbee DE, de Jong PT, et al. Determinants of disease and disability in the elderly: the Rotterdam Elderly Study. Eur J Epidemiol. 1991;7(4):403–22.

    CAS  PubMed  Article  Google Scholar 

  15. 15.

    Hofman A, Breteler MM, van Duijn CM, et al. The Rotterdam Study: objectives and design update. Eur J Epidemiol. 2007;22(11):819–29.

    PubMed Central  PubMed  Article  Google Scholar 

  16. 16.

    Hofman A, Breteler MMB, van Duijn CM, et al. The Rotterdam Study: 2010 objectives and design update. Eur J Epidemiol. 2009;24(9):553–72.

    PubMed Central  PubMed  Article  Google Scholar 

  17. 17.

    Ikram MA, van der Lugt A, Niessen WJ, et al. The Rotterdam Scan Study: design and update up to 2012. Eur J Epidemiol. 2011;26(10):811–24.

    PubMed Central  PubMed  Article  Google Scholar 

  18. 18.

    Hofman A, Darwish Murad S, van Duijn CM, et al. The Rotterdam Study: 2014 objectives and design update. Eur J Epidemiol. 2013;28(11):889–926.

    CAS  PubMed  Article  Google Scholar 

  19. 19.

    de Vries NM, Staal JB, van Ravensberg CD, et al. Outcome instruments to measure frailty: a systematic review. Ageing Res Rev. 2011;10(1):104–14.

    PubMed  Article  Google Scholar 

  20. 20.

    Radloff LS. The CES-D scale: a self-report depression scale for research in the general population. Appl Psychol Meas. 1977;1(3):385–401.

    Article  Google Scholar 

  21. 21.

    Taylor HL, Jacobs DR Jr, Schucker B, et al. A questionnaire for the assessment of leisure time physical activities. J Chronic Dis. 1978;31(12):741–55.

    CAS  PubMed  Article  Google Scholar 

  22. 22.

    Executive summary: standards of medical care in diabetes–2013. Diabetes Care. 2013;36(Suppl 1):S4–S10.

  23. 23.

    Lahousse L, van den Bouwhuijsen Q, Loth DW, et al. Chronic obstructive pulmonary disease and lipid core carotid artery plaques in the Elderly: the Rotterdam Study. Am J Respir Crit Care Med. 2013;187(1):58–64.

    CAS  PubMed  Article  Google Scholar 

  24. 24.

    European Society of Hypertension. European Society of Cardiology guidelines for the management of arterial hypertension. J Hypertens. 2003;21(6):1011–53.

    Article  Google Scholar 

  25. 25.

    WHO. Assessment of fracture risk and its application to screening for postmenopausal osteoporosis. Report of a WHO Study Group. World Health Organization Technical Report Series. 1994;843:1–129.

  26. 26.

    Levey AS, Coresh J, Balk E, et al. National Kidney Foundation practice guidelines for chronic kidney disease: evaluation, classification, and stratification. Ann Intern Med. 2003;139(2):137–47.

    PubMed  Article  Google Scholar 

  27. 27.

    Levey AS, Coresh J, Greene T, et al. Expressing the Modification of Diet in Renal Disease Study equation for estimating glomerular filtration rate with standardized serum creatinine values. Clin Chem. 2007;53(4):766–72.

    CAS  PubMed  Article  Google Scholar 

  28. 28.

    World Health Organization. Haemoglobin concentrations for the diagnosis of anaemia and assessment of severity. Vitamin and Mineral Nutrition Information System, Geneva. 2011.

  29. 29.

    Kiely DK, Cupples LA, Lipsitz LA. Validation and comparison of two frailty indexes: the MOBILIZE Boston Study. J Am Geriatr Soc. 2009;57(9):1532–9.

    PubMed Central  PubMed  Article  Google Scholar 

  30. 30.

    Morley JE, Haren MT, Rolland Y, et al. Frailty. Med Clin North Am. 2006;90(5):837–47.

    PubMed  Article  Google Scholar 

  31. 31.

    Cruz-Jentoft AJ, Baeyens JP, Bauer JM, et al. Sarcopenia: European consensus on definition and diagnosis: report of the European working group on sarcopenia in older people. Age Ageing. 2010;39(4):412–23.

    PubMed Central  PubMed  Article  Google Scholar 

  32. 32.

    Chaves PH, Semba RD, Leng SX, et al. Impact of anemia and cardiovascular disease on frailty status of community-dwelling older women: the Women’s Health and Aging Studies I and II. J Gerontol A Biol Sci Med Sci. 2005;60(6):729–35.

    PubMed  Article  Google Scholar 

  33. 33.

    Leng SX, Xue QL, Tian J, et al. Inflammation and frailty in older women. J Am Geriatr Soc. 2007;55(6):864–71.

    PubMed  Article  Google Scholar 

  34. 34.

    Ershler WB, Keller ET. Age-associated increased interleukin-6 gene expression, late-life diseases, and frailty. Annu Rev Med. 2000;51:245–70.

    CAS  PubMed  Article  Google Scholar 

  35. 35.

    Gill TM, Gahbauer EA, Allore HG, et al. Transitions between frailty states among community-living older persons. Arch Intern Med. 2006;166(4):418–23.

    PubMed  Article  Google Scholar 

  36. 36.

    Hamerman D. Toward an understanding of frailty. Ann Intern Med. 1999;130(11):945–50.

    CAS  PubMed  Article  Google Scholar 

  37. 37.

    Verdery RB. Failure to thrive in older people. J Am Geriatr Soc. 1996;44(4):465–6.

    CAS  PubMed  Google Scholar 

  38. 38.

    Gill TM, Baker DI, Gottschalk M, et al. A program to prevent functional decline in physically frail, elderly persons who live at home. N Engl J Med. 2002;347(14):1068–74.

    PubMed  Article  Google Scholar 

  39. 39.

    Ganz DA, Higashi T, Rubenstein LZ. Monitoring falls in cohort studies of community-dwelling older people: effect of the recall interval. J Am Geriatr Soc. 2005;53(12):2190–4.

    PubMed  Article  Google Scholar 

Download references


The authors thank the study participants, the staff from the Rotterdam Study, J. Verkroost, F. van Rooij, M. Leening, R. Ruiter and the participating general practitioners. This study was supported by the Fund for Scientific Research Flanders (FWO) project G035014 N. The funding source had no involvement in the collection, analysis, writing, interpretation, nor in the decision to submit the paper for publication. Researchers were independent from funders for this work.

Conflict of interest

None of the authors has important conflicts of interest with relevance to the submitted work.

Author information



Corresponding author

Correspondence to Bruno H. Stricker.

Additional information

Lies Lahousse and Bastiaan Maes have contributed equally to this work.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary material 1 (DOCX 15 kb)

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Lahousse, L., Maes, B., Ziere, G. et al. Adverse outcomes of frailty in the elderly: the Rotterdam Study. Eur J Epidemiol 29, 419–427 (2014).

Download citation


  • Frail elderly
  • Weight loss
  • Grip strength
  • Physical activity
  • Mortality