Reproducibility of the Brazilian version of the Edmonton Frail Scale for elderly living in the community 1

Copyright © 2013 Revista Latino-Americana de Enfermagem This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (CC BY-NC). This license lets others distribute, remix, tweak, and build upon your work non-commercially, and although their new works must also acknowledge you and be non-commercial, they don’t have to license their derivative works on the same terms. Corresponding Author: Rosalina Aparecida Partezani Rodrigues Universidade de São Paulo. Escola de Enfermagem de Ribeirão Preto Departamento de Enfermagem Geral e Especializada Avenida Bandeirantes, 3900 Bairro: Monte Alegre CEP: 14040-902, Ribeirão Preto, SP, Brasil E-mail: rosalina@eerp.usp.br Suzele Cristina Coelho Fabrício-Wehbe2 Idiane Rosset Cruz3 Vanderlei José Haas4 Marina Aleixo Diniz5 Rosana Aparecida Spadoti Dantas6 Rosalina Aparecida Partezani Rodrigues7


Introduction
In the opinion of researchers and healthcare professionals, frailty can undoubtedly cause a negative impact in the life of the elderly, their families, caregivers and the society. In the national and international literature, there is a consensus that frailty represents a non-optimal and multifactorial clinical condition that is vulnerable to adverse effects upon lesser impact stressors (1)(2)(3) .
Currently, this syndrome emerges as an important event to public health because it is associated to adverse health outcomes, such as functional decline, dependency, recurrent falls, fractures, institutionalization, hospitalization and mortality of the elderly from both genders. It is still believed that there is a strong relationship between frailty and comorbidities, which can cause people with this syndrome to be more susceptible to diseases (6)(7)(8)(9) .
Due to these factors, researchers defend the theory that early detection of frailty is very important, that the disabilities resulting from it are a lot better treated and have better prognosis when detected in the first months of occurrence. Interventions are more effective when performed in the initial stages of frailty (10)(11) .
For this early detection, however, it is necessary to know an instrument that is easy for healthcare professionals to understand and administer, so that it is possible to accurately and safely detect the frailty indicators in elderly people.
To assist with this search, a group of Canadian researchers (12) studied a clinical proposal to detect frailty in elderly people and proposed a scale to assess it: the It was considered valid and reliable within the elderly group subject of the study and a valuable frailty research tool (13) .
In Taiwan, researchers investigated the prevalence of frailty in people aged between 65 and 80 living in the community using the EFS, and compared it with the prevalence showed by another instrument, the Fried Frailty Index (FFI) (14) . In England, researchers from the Oxford Project to Investigate Memory and Aging (OPTIMA) used, amongst other instruments, the EFS to verify the relationship between neurocognitive speeds and elderly frailty, during three years of study (15) .
In Brazil, researchers performed the cultural adaptation of the scale with people aged 65 or over living in the community. The construct and criteria validity of the scale, as well as the internal consistency of the items, were verified and considered valid in relation to the sample studied (16) .
The reproducibility of an instrument, however, should also be analyzed. Reliability, reproducibility and accuracy are terms used to assess an important psychometric property of assessment instruments of subjective constructs, which is the reliability of the measure (17) . The analysis of the inter-rater reliability is performed to estimate possible errors during the administration that may be caused by the differences between evaluators (inter-rater test), while in the intra-rater reliability the same evaluator administers the instrument more than once (test-retest). In the first case, if the two evaluators properly follow the instructions for the use of the instrument, the results should be consistent between them. In the second case, if the construct to be measured does not change, the measures obtained should be similar (17)(18) . severe frailty (16) .
The data were entered into EXCEL through the double entry validation technique. When data entry and data consistency were concluded, the data were

Discussion
In a recent systematic review of the international literature, it could be noted that there still does not exist a single frailty assessment model for the elderly that is accepted by the researchers. But there are instruments using different parameters and concepts (19) .
In Brazil, there is extensive use of the frailty phenotype developed by the Cardiovascular Health Study (CHS) (6) . The EFS started to be used after recent publications about its cultural adaptation to Brazil (16) .
An instrument can, however, be valid with low reliability, and there could be instruments with high reliability without validity (20) , thus the need to analyze the maximum possible number of psychometric properties in a scale. Therefore, the reproducibility of the EFS was assessed in this study. In this study, the reproducibility of the scale was verified through the testretest and intra-rater.
In relation to the intra and inter-rater reliability, it could be noted that the lowest agreement in the answers was obtained for the items that depended on the answer of the elderly, especially in more subjective items, and not on the evaluators' assessment, showing that the commitment of the participants interviewed may alter the answers. In addition, it is possible that the demographic, socioeconomic and cultural characteristics of the participants affect, even if partially, some of the answers.
The authors of the original scale only determined the inter-rater reliability, which was re-administered within 24 hours (12) . To test the reliability between the evaluators of the EFS, these authors used the Kappa understand the care practices directed to the elderly by the family caregiver. The care practices vary according to the needs of the elderly, the environment, the family structure, and the knowledge of each family (22) . The use of the EFS is a strategy used to assess the elderly and can be used by various healthcare professionals to better direct the care practices to be implemented according to the specific needs of the elderly. The identification of these elderly people should be mainly considered by primary healthcare professionals who directly work with this population, since there is the possibility of an immediate intervention in order to keep this status unchanged (23) .
One limitation of this study is related to the lack of assessment of the sensitivity and responsiveness of the EFS. The authors are already elaborating these analyses, as well as its predictive validity.
It is necessary to further investigate the administration of this scale in the elderly severely compromised in our environment and those living in institutions, since it has only been administered to the elderly living in the community. Also, during the study, the elderly clinically and severally compromised were not interviewed.

Conclusions
Through the statistical analysis of the results of this research, the EFS was considered reliable and with good reproducibility. Given that this scale is easy and practical to administer, it can be used by a multidisciplinary team and even by people who are not specialized in the area, but properly trained to assess frailty in elderly people.
The use of a scale to identify frailty can permit a less conceptual and more operational understanding of this syndrome in clinical practice. Its use by healthcare professionals will support the prevention of diseases and promotion of health, since it can be used to detect prefrailty in elderly people.
The scale was shown to be useful when administered to healthy elderly people or those with Non-transmissible Chronic Diseases (DCNTs) living in the community.
However, its administration could include scenarios of chronic health situations, such as outpatient care centers or long stay institutions.
The translation of the EFS to Portuguese and its cultural adaption to a sample of elderly Brazilians, as well as the demonstration of its validity and reproducibility, make the use of this scale feasible in the frailty diagnosis of elderly people.