Editorial| Volume 37, ISSUE 11, P1702-1704, November 2021

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The Crying Need for Validated Consensus Frailty Measurement Standards: Will the Real Frailty Please Stand Up?

  • George A. Heckman
    Corresponding author: Dr George A. Heckman, Schlegel Research Chair in Geriatric Medicine, Associate Professor, School of Public Health and Health Systems, Faculty of Applied Health Sciences, University of Waterloo, TJB 2264, 200 University Avenue West, Waterloo, Ontario N2L 3G1, Canada. Tel.: +1-519-888-4567, ext 41028.
    Schlegel Research Institute for Aging, Waterloo, Ontario, Canada

    School of Public Health and Health Systems, University of Waterloo, Waterloo, Ontario, Canada
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  • Luke Turcotte
    School of Public Health and Health Systems, University of Waterloo, Waterloo, Ontario, Canada
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  • John P. Hirdes
    School of Public Health and Health Systems, University of Waterloo, Waterloo, Ontario, Canada
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Published:September 29, 2021DOI:
      In the television game show “To Tell the Truth” (incidentally occasionally sponsored by the makers of Geritol), panelists try to identify a mystery guest among 3 pretenders.
      Wikipedia. To Tell the Truth.
      To Tell the Truth: Dr. Seuss.
      Following a question and answer period, the panelists guess which pretender is the real mystery guest. The mystery guest is finally identified among the pretenders when asked by the host to “please stand up.” In gerontology today, frailty is akin to the mystery guest. Numerous operationalisations of frailty having been proposed; however, unlike the game show’s successful conclusion, the worldwide panel of gerontologic experts has yet to agree on a standard approach to measure frailty.
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      1. Wikipedia. To Tell the Truth.
        (Available at:)
        Date accessed: September 25, 2021
      2. To Tell the Truth: Dr. Seuss.
        (Available at:)
        Date accessed: September 25, 2021
        • Rolfson D.B.
        • Heckman G.A.
        • Bagshaw S.M.
        • Robertson D.
        • Hirdes J.P.
        Implementing frailty measures in the Canadian healthcare system.
        J Frailty Aging. 2018; 7: 208-216
        • 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. 2019; 157: 1905-1909
        • O’Neill D.E.
        • Forman D.E.
        Cardiovascular care of older adults.
        BMJ. 2021; 374: n1593
        • Tjam E.Y.
        • Heckman G.A.
        • Smith S.
        • et al.
        Predicting heart failure mortality in frail seniors: comparing the NYHA functional classification with the Resident Assessment Instrument (RAI) 2.0.
        Int J Cardiol. 2012; 155: 75-80
        • Smith C.R.
        Frailty is to predictive as Jello is to wall.
        J Thorac Cardiovasc Surg. 2018; 156: 177
        • Buta B.J.
        • Walston J.D.
        • Godino J.G.
        • et al.
        Frailty assessment instruments: systematic characterization of the uses and contexts of highly-cited instruments.
        Ageing Res Rev. 2016; 26: 53-61
        • Goldfarb M.
        • Afilalo J.
        Cardiac rehabilitation: are we missing an important means to defrail and reverse adverse consequences of aging?.
        Can J Cardiol. 2020; 36: 457-458
        • Kehler D.S.
        • Giacomantonio N.
        • Firth W.
        • et al.
        Association between cardiac rehabilitation and frailty.
        Can J Cardiol. 2020; 36: 482-489
        • Li Z.
        • Habbous S.
        • Thain J.
        • Hall D.E.
        • et al.
        Cost-effectiveness analysis of frailty assessment in older patients undergoing coronary artery bypass grafting surgery.
        Can J Cardiol. 2020; 36: 490-499
        • Dhaliwal G.
        • Detsky A.S.
        The evolution of the master diagnostician.
        JAMA. 2013; 310: 579-580
        • Negm A.M.
        • Kennedy C.C.
        • Thabane L.
        • et al.
        Management of frailty: a systematic review and network meta-analysis of randomized controlled trials.
        J Am Med Dir Assoc. 2019; 20: 1190-1198
        • O’Caoimh R.
        • Sezgin D.
        • O’Donovan M.R.
        • et al.
        Prevalence of frailty in 62 countries across the world: a systematic review and meta-analysis of population-level studies.
        Age Ageing. 2021; 50: 96-104
        • Fountotos R.
        • Munir H.
        • Goldfarb M.
        • et al.
        Prognostic value of handgrip strength in older adults undergoing cardiac surgery.
        Can J Cardiol. 2021; 37: 1760-1766
        • Surkan M.
        • Rajabali N.
        • Bagshaw S.
        • Wang X.
        • Rolfson D.
        Interrater reliability of the Clinical Frailty Scale by geriatrician and intensivist in patients admitted to the intensive care unit.
        Can Geriatr J. 2020; 23: 235-241
        • Theou O.
        • Pérez-Zepeda M.U.
        • van der Valk A.M.
        • et al.
        A classification tree to assist with routine scoring of the Clinical Frailty Scale.
        Age Ageing. 2021; 50: 1406-1411
        • Jha S.R.
        • Hannu M.K.
        • Newton P.J.
        • et al.
        Reversibility of frailty after bridge-to-transplant ventricular assist device implantation or heart transplantation.
        Transplant Direct. 2017; 3: e167
        • Searle S.D.
        • Mitnitski A.
        • Gahbauer E.A.
        • Gill T.M.
        • Rockwood K.
        A standard procedure for creating a frailty index.
        BMC Geriatr. 2008; 8: 24
        • Campitelli M.A.
        • Bronskill S.E.
        • Hogan D.B.
        • Diong C.
        • Amuah J.E.
        • Gill S.
        • et al.
        The prevalence and health consequences of frailty in a population-based older home care cohort: a comparison of different measures.
        BMC Geriatr. 2016; 16: 133
        • Beckett N.S.
        • Peters R.
        • Fletcher A.E.
        • et al.
        • HYVET Study Group
        Treatment of hypertension in patients 80 years of age or older.
        N Engl J Med. 2008; 358: 1887-1898
        • Warwick J.
        • Falaschetti E.
        • Rockwood K.
        • et al.
        No evidence that frailty modifies the positive impact of antihypertensive treatment in very elderly people: an investigation of the impact of frailty upon treatment effect in the Hypertension in the Very Elderly Trial (HYVET) study, a double-blind, placebo-controlled study of antihypertensives in people with hypertension aged 80 and over.
        BMC Med. 2015; 13: 78
      3. SPRINT Research Group; Wright JT Jr, Williamson JD, Whelton PK, et al. A randomized trial of intensive versus standard blood-pressure control. N Engl J Med 2015;373:2103-2116. Erratum: N Engl J Med 2017;377:2506.

        • Pajewski N.M.
        • Williamson J.D.
        • Applegate W.B.
        • et al.
        • SPRINT Study Research Group
        Characterizing frailty status in the systolic blood pressure intervention trial.
        J Gerontol A Biol Sci Med Sci. 2016; 71: 649-655
        • Giffin A.
        • Madden K.M.
        • Hogan D.B.
        Blood pressure targets for older patients-do advanced age and frailty really not matter?.
        Can Geriatr J. 2020; 23: 205-209
        • Sexton D.J.
        • Canney M.
        • O’Connell M.D.L.
        • et al.
        Injurious falls and syncope in older community-dwelling adults meeting inclusion criteria for SPRINT.
        JAMA Intern Med. 2017; 177: 1385-1387
        • Azad N.A.
        • Mielniczuk L.
        A call for collaboration: improving cardiogeriatric care.
        Can J Cardiol. 2016; 32: 1041-1044

      Linked Article

      • Prognostic Value of Handgrip Strength in Older Adults Undergoing Cardiac Surgery
        Canadian Journal of CardiologyVol. 37Issue 11
        • Preview
          Although multidimensional frailty scales have been proven to predict mortality and morbidity in cardiac surgery, there is a need for rapid tools that could be easily administered at the point of care. Handgrip strength (HGS) is an attractive option that can be measured in acutely ill and bed-bound patients, although it has yet to be validated in a large cardiac surgery cohort.
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