Try This: The Frailty Index for Elders (FIFE)

Issue #34 of General Assessment Series

WHY: The risk for becoming frail increases as older adults live longer with chronic illnesses. Frailty is a geriatric syndrome affecting older adults due to multisystem decline that increases vulnerability to poor health effects. Although there is not a universal gold standard definition of frailty, there are two main definitions currently accepted. The Phenotype of Frailty identifies older adults as frail if they have three or more of five criteria and being at risk for frailty is having one or two criteria: slow walking speed, weak grip strength, exhaustion, low physical activity level, and unintentional weight loss (Fried et al., 2001). Alternately, a Frailty Index includes cognition, mood and social resources with physiological components in defining frailty (Rockwood et al., 2005). The hallmark of frailty is its progressive decline marked by loss of function, loss of physiological reserve, increased risk for falls, delayed illness recovery, more frequent and longer stay hospitalization, and mortality. Even small stressors of temperature change or the common cold may precipitate a spiraling downward trajectory for frail older adults with significant impact on the quality of life of the older adult and families. Once frail, it is difficult to reverse the downward decline. Therefore, it is essential to recognize older adults at risk for frailty in the clinical setting. Early recognition of older adults at risk for frailty can lead to interventions that may prevent or ameliorate frailty.

BEST TOOL: The Frailty Index for Elders (FIFE) was developed to assess for frailty risk in older adults using items collected in existing nursing datasets. This maximizes the use of data collected during nursing assessment and reduces testing fatigue for the patient, family, and nurse. FIFE is a 10-item assessment instrument with scores ranging from 0-10. A score of 0 indicates no frailty; a score of 1-3 indicates frailty risk; and a score of 4 or greater indicates frailty.

TARGET POPULATION: All older adults with multiple health problems.

VALIDITY AND RELIABILITY: FIFE has strong validity (content validity analysis range 0.50-1.0). The reliability of FIFE is low (range 0.39-0.60). However, this may be interpreted as a strength as frailty is a fluid concept and events may never be exactly duplicated due to changes in an individual’s health and perspective of an individual’s health status.

STRENGTHS AND LIMITATIONS: The major strengths of the FIFE is the rigorous scientific inquiry utilized for instrument development and items that support the multidimensional nature of frailty and human health. All items were developed through a triangular process involving standard procedures for assessing and evaluating reliability and validity. FIFE items are easily extrapolated from holistic research and existing nursing datasets. For clinicians, the FIFE may be used as an assessment instrument with the use of all items to determine frailty and individual items to determine risk for frailty. For researchers, the FIFE may be used to (1) study multiple determinants of frailty; (2) compare frailty among older adult populations using standardized measures; (3) inform the development of interventional studies designed to prevent or thwart frailty; and (4) function as a quality of life outcome.

FOLLOW-UP: The clinical application of the FIFE would be enhanced with established cut-off points to determine non-frail versus pre-frail (at risk for frailty) versus frail. Future psychometric analysis of the predictive properties of FIFE will allow for the determination of empirically-based cut-off points.


Fried, L. P., Tangen, C. M., Walston, J., Newman, A. B., Hirsch, C., Gottdiener, J., Seeman, T., Tracy, R., Kop, W. J., Burke, G., McBurnie, M. A., & Cardiovascular Health Study Collaborative Research Group. (2001). Frailty in older adults: Evidence for a phenotype. Journals of Gerontology Series A-Biological Sciences & Medical Sciences, 56A(3), M146-156.

Rockwood, K., Song, X., MacKnight, C., Bergman, H., Hogan, D. B., McDowell, I., & Mitnitski, A. (2005). A global clinical measure of fitness and frailty in elderly people. Canadian Medical Association Journal, 173(5), 489-495.

Tocchi, C., Dixon, J., Naylor, M., Sangchoon, J., & McCorkle, R. (2014). Development of a frailty index measure for older adults: The Frailty Index for Elders. Journal of Nursing Measurement, 22(2), 223-240.

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