Skip to main content

A Novel Tool for the Early Identification of Frailty in Elderly People: The Application in Primary Care Settings



Frailty is a pre-disability condition in older persons providing a challenge to Health-Care Systems. Systematic reviews highlight the absence of a gold-standard for its identification. However, an approach based on initial screening by the General Practitioner (GP) seems particularly useful. On these premises, a 9-item Sunfrail Checklist (SC), was developed by a multidisciplinary group, in the context of European Sunfrail Project, and tested in the Community.


To measure the concordance between the judgments of frailty (criterion-validity): the one formulated by the GP, using the SC, and the one subsequently expressed by a Comprehensive Geriatric Assessment Team (CGA-Team); — to determine the construct-validity through the correspondence between some checklist items related to the 3 domains (physical, cognitive and social) and the three tools used by the CGA-Team; — to measure the instrument’s performance in terms of positive predictive value (PPV) and negative predictive value (NPV).


Cross-sectional study, with a final sample-size of 95 subjects.


Two Community-Health Centers of Parma, Italy.


Subjects aged 75 years old or more, with no disability and living in the community.


We compared the screening capacity of the GP using the SC to that one of CGA-Team based on three tests: 4-meter Gait-Speed, Mini-Mental State Examination and Loneliness Scale.


95 subjects (51 women), with a mean age of 81±4 years were enrolled. According to GPs 34 subjects were frail; the CGA-Team expressed a frailty judgment on 26 subjects. The criterion-validity presented a Cohen’s k of 0.353. Construct-validity was also low, with a maximum contingency-coefficient of 0.19. The analysis showed a PPV of 58.1% and a NPV equal to 84.6%.


Our data showed a low agreement between the judgements of GP performed by SC and CGA-Team. However, the good NPV suggests the applicability of SC for screening activities in primary-care.

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

Figure 1


  1. Sacha J, Sacha M, Soboń J, Borysiuk Z, Feusette P. Is It Time to Begin a Public Campaign Concerning Frailty and Pre-frailty? A Review Article. Front Physiol. 2017 Jul;8:484.

    Article  Google Scholar 

  2. Gobbens RJ, van Assen MA, Luijkx KG, Schols JM. Testing an integral conceptual model of frailty. J Adv Nurs. 2012 Sep;68(9):2047–60.

    Article  Google Scholar 

  3. Sutorius FL, Hoogendijk EO, Prins BA, van Hout HP. Comparison of 10 single and stepped methods to identify frail older persons in primary care: diagnostic and prognostic accuracy. BMC Fam Pract. 2016 Aug;17:102.

    Article  Google Scholar 

  4. Cesari M, Prince M, Thiyagarajan JA, et al. Frailty: An Emerging Public Health Priority. J Am Med Dir Assoc. 2016 Mar;17(3):188–92.

    Article  Google Scholar 

  5. van Kempen JA, Schers HJ, Jacobs A et al. Development of an instrument for the identification of frail older people as a target population for integrated care. Br J Gen Pract. 2013 Mar;63(608):e225–31.

    Article  Google Scholar 

  6. van Kempen JA, Schers HJ, Melis RJ, Olde Rikkert MG. Construct validity and reliability of a two-step tool for the identification of frail older people in primary care. J Clin Epidemiol. 2014 Feb;67(2):176–83.

    Article  Google Scholar 

  7. Kelley K, Clark B, Brown V, Sitzia J. Good practice in the conduct and reporting of survey research. Int J Qual Health Care. 2003 Jun;15(3):261–6.

    Article  Google Scholar 

  8. Burns KE, Duffett M, Kho ME et al; ACCADEMY Group. A guide for the design and conduct of self-administered surveys of clinicians. CMAJ. 2008 Jul 29;179(3):245–52.

    Article  Google Scholar 

  9. Bennett C, Khangura S, Brehaut JC et al. Reporting guidelines for survey research: an analysis of published guidance and reporting practices. PLoS Med. 2010 Aug;8(8):e1001069.

    Article  Google Scholar 

  10. Rolfson DB, Majumdar SR, Tsuyuki RT, Tahir A, Rockwood K. Validity and reliability of the Edmonton Frail Scale. Age Ageing. 2006 Sep;35(5):526–9.

    Article  Google Scholar 

  11. Gobbens RJ, van Assen MA, Luijkx KG, Wijnen-Sponselee MT, Schols JM. The Tilburg Frailty Indicator: psychometric properties. J Am Med Dir Assoc. 2010 Jun;11(5):344–55.

    Article  Google Scholar 

  12. Tavassoli N, Guyonnet S, Abellan Van Kan G et al; Geriatric Frailty Clinic (G.F.C) for Assessment of Frailty and Prevention of Disability Team. Description of 1,108 older patients referred by their physician to the “Geriatric Frailty Clinic (G.F.C) for Assessment of Frailty and Prevention of Disability” at the gerontopole. J Nutr Health Aging. 2014 May;18(5):457

    CAS  Article  Google Scholar 

  13. Peel NM, Kuys SS, Klein K. Gait speed as a measure in geriatric assessment in clinical settings: a systematic review. J Gerontol A Biol Sci Med Sci. 2013 Jan;68(1):39–46.

    Article  Google Scholar 

  14. Folstein MF, Folstein SE, McHugh PR. “Mini-mental state”. A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975 Nov;12(3):189–98.

    CAS  Article  Google Scholar 

  15. Boffo M, Mannarini S, Munari C. Exploratory Structure Equation Modeling of the UCLA Loneliness Scale: A contribution to the Italian adaptation. TPM. 2012;19(4):345–363.

    Google Scholar 

  16. British Geriatric Society. Comprehensive Assessment of the Frail Older Patient. January 2010.

  17. Altman DG. Practical statistics for medical research. 1st edition. Oxford: Chapman and Hall 1991;1–611

    Google Scholar 

  18. Cohen J. A power primer. Psychol Bull. 1992 Jul;112(1):155–9.

    CAS  Article  Google Scholar 

  19. Onder G, Cesari M, Maggio M, Palmer K. Defining a care pathway for patients with multimorbidity or frailty. Eur J Intern Med. 2017 Mar;38:1–2.

    Article  Google Scholar 

  20. Roe L, O’Halloran A, Normand C, Murphy C. The impact of frailty on public health nurse service utilisation. Report from the TILDA study. 2016. Available on:

  21. Cawthon PM, Travison TG, Manini TM et al; Sarcopenia Definition and Outcomes Consortium Conference participants. Establishing the Link Between Lean Mass and Grip Strength Cut-points With Mobility Disability and Other Health Outcomes: Proceedings of the Sarcopenia Definition and Outcomes Consortium Conference. J Gerontol A Biol Sci Med Sci. 2019 Mar

  22. Tang-Wai DF, Knopman DS, Geda YE et al. Comparison of the short test of mental status and the mini-mental state examination in mild cognitive impairment. Arch Neurol. 2003 Dec;60(12):1777–81.

    Article  Google Scholar 

  23. Poulin J, Deng R, Ingersoll TS, Witt H, Swain M. Perceived family and friend support and the psychological well-being of American and Chinese elderly persons. J Cross Cult Gerontol. 2012 Dec;27(4):305–17.

    Article  Google Scholar 

  24. Ruiz JG, Priyadarshni S, Rahaman Z et al. Validation of an automatically generated screening score for frailty: the care assessment need (CAN) score. BMC Geriatr. 2018 May;18(1):106.

    Article  Google Scholar 

Download references


We would like to thanks all the GPs and the participants involved.


Funding: The SUNFRAIL (project 664291), has received funding from the European Union’s Health Programme (2014–2020).

Author information

Authors and Affiliations


Corresponding author

Correspondence to Marcello Maggio.

Ethics declarations

Ethical standards: The project was approved by the local ethics committee on 12 december 2017, protocol number 44605.

Additional information

Conflicts of Interest: All the authors have nothing to disclose.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Maggio, M., Barbolini, M., Longobucco, Y. et al. A Novel Tool for the Early Identification of Frailty in Elderly People: The Application in Primary Care Settings. J Frailty Aging 9, 101–106 (2020).

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI:

Key words

  • Ageing
  • frailty
  • multimorbidity
  • integrated care
  • sunfrail