Clinical-Functional Vulnerability Index-20 (IVCF-20): rapid recognition of frail older adults

Moraes, Edgar Nunes de; Carmo, Juliana Alves do; Moraes, Flávia Lanna de; Azevedo, Raquel Souza; Machado, Carla Jorge; Montilla, Dalia Elena Romero

doi:10.1590/S1518-8787.2016050006963

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Original Articles • Rev. Saúde Pública 50 • 2016 • https://doi.org/10.1590/S1518-8787.2016050006963 copy

Clinical-Functional Vulnerability Index-20 (IVCF-20): rapid recognition of frail older adults

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

OBJECTIVE

To evaluate the adequacy of the Clinical-Functional Vulnerability Index-20, a rapid triage instrument to test vulnerability in Brazilian older adults, for the use in primary health care.

METHODS

The study included convenience sample of 397 patients aged older than or equal to 60 years attended at Centro de Referência para o Idoso (Reference Center for Older Adults) and of 52 older adults the same age attended at the community. The results of the questionnaire, consisting of 20 questions, were compared with those of the Comprehensive Geriatric Assessment, considered a reference for identifying frail older adults. Spearman’s correlation was evaluated in the Clinical-Functional Vulnerability Index-20 with the Comprehensive Geriatric Assessment; the validity was verified by the area under the ROC curve; reliability was estimated by the percentage of agreement among evaluators and by the kappa coefficient, both with quadratic weighted. The cut-off point was obtained based on the higher accuracy criterion. Cronbach’s alpha, a measure of internal consistency, was estimated.

RESULTS

The Spearman’s correlation coefficient was high and positive for both groups (0.792 for older adults attended at the Reference Center and 0.305 for older adults from the community [p < 0.001]). The area under the ROC curve for older adults attended at the Reference Center was substantial (0.903). The cut-off point obtained was six, and older adults with scores in Clinical-Functional Vulnerability Index-20 above that value had strong possibility of being frail. For older adults from the community, the quadratic weighted agreement among evaluators was 99.5%, and the global quadratic weighted kappa coefficient was 0.94. Cronbach’s alpha was high for older adults attended at the Reference Center (0.861) and those attended at the community (0.740).

CONCLUSIONS

The Clinical-Functional Vulnerability Index-20 questionnaire, in the sample examined, turned out to be positively correlated with the Comprehensive Geriatric Assessment, in addition to the results indicating a high degree of validity and reliability. Thus, the Clinical-Functional Vulnerability Index-20 proves to be viable as a triage instrument in the primary health care that identifies frail older adults (older adults at risk of weakening and frail older adults).

Frail Elderly; Geriatric Assessment; Triage, methods; Primary Health Care; Health Vulnerability

Group	Stratum	Clinical-Functional classification
Robust older adults	Stratum 1	They are at their maximum degree of vitality. They present independence for all advanced, instrumental, or basic activities of daily living, and absence of disease or risk factors except age itself.
	Stratum 2	They are independent for all activities of daily living, but present health conditions of low clinical complexity, such as uncomplicated hypertension or presence of risk factors such as smoking, dyslipidemia, osteopenia, among others.
	Stratum 3	They are independent for all activities of daily living, but present well established chronic-degenerative diseases of higher complexity, such as complicated hypertension, diabetes mellitus, history of transient ischemic attack, cerebrovascular accident without sequelae, chronic kidney disease, heart failure, chronic obstructive pulmonary disease, osteoarthritis, coronary artery disease, peripheral artery disease, osteoporosis, atrial fibrillation, depression, among others. In these older adults, such diseases are not associated with functional impairment and are presented in isolation. In this group, are also included older adults who feature one or two criteria of the “fragility phenotype”, according to Fried and Ferrucci⁴.
Older adults at risk of frail	Stratum 4	They are independent for all activities of daily living, but present predictive conditions of adverse outcomes represented by the higher risk of functional decline established, institutionalization, or death: presence of sarcopenia markers, mild cognitive impairment, or multiple comorbidities (polypathology, polypharmacy, or recent hospitalization). In this group, are included older adults who have three or more criteria of the “fragility phenotype”, according to Fried and Ferrucci⁴.
Older adults at risk of frail	Stratum 5	They present predictive conditions of adverse outcomes (as in Stratum 4), but have functional decline in activities of daily living, associated with leisure, work, or social interaction. These older adults are still independent for instrumental and basic activities of daily living.
Frail older adults	Stratum 6	They present partial functional decline in instrumental activities of daily living and are independent for the basic activities.
	Stratum 7	They present functional decline in all instrumental activities of daily living, but are still independent for the basic activities.
	Stratum 8	They present complete dependency in instrumental activities of daily living associated with the semi-dependence in the basic activities: impairment of one of the functions influenced by culture and learning – bathing, dressing up, and using the toilet.
	Stratum 9	They present complete dependency in instrumental activities of daily living associated with the incomplete dependence in the basic activities: impairment of one of the simple vegetative functions (transfer and continence), in addition to clearly being dependent for bathing, dressing up, and using the toilet. The isolated presence of urinary incontinence should not be considered.
	Stratum 10	They are at their maximum degree of fragility and, consequently, have the most functional dependency, needing help even to feed themselves.

Clinical-Functional Vulnerability Indicators	CRI		Health Center

	n	%	n	%
Age in years
60-74	178	44.8	39	75.0
75-84	162	40.8	11	21.2
≥ 85	57	14.4	2	3.9
Regular or bad self-perception of health	236	59.5	10	19.2
Functional disabilities
Disability in at least one instrumental ADL	154	38.8	1	1.9
Stopped bathing alone for physical condition – basic ADL	58	14.6	1	1.9
Cognition
A relative or friend mentioned forgetfulness of the patient	245	61.7	5	9.6
Worsening of forgetfulness in the last months^b	176	71.8^a	2	40.0^a
Forgetfulness prevents performing some daily activity	129	52.7^a	0	0^a
Mood
Dismay, sadness, or hopelessness in the last month	204	51.4	2	3.9
Loss of interest or pleasure, in the last month, in previously enjoyable activities	126	31.7	2	3.9
Mobility: reach, graspingness, and pincer grip
Inability to raise the arm above shoulder level	35	8.8	0	0
Inability to handle or hold small objects	26	6.6	0	0
Aerobic and muscle capacity
Unintentional weight loss^c or BMI < 22 kg/m² or calf circumference < 31 cm or time during the gait speed test from 4 min > 5 sec.	172	43.3	3	5.8
Gait
Two or more falls in the last year	122	30.7	4	7.7
Walking difficulties preventing to perform some daily activity	109	27.5	1	1.9
Sphincteral incontinence: involuntary loss of urine or feces	189	47.6	9	17.3
Communication
Vision problems that may prevent the performance of some daily activity^d	75	18.9	1	1.9
Hearing problems that may prevent the performance of some daily activity^e	63	15.9	1	1.9
Multiple comorbidities: five or more chronic diseases or daily use of five or more different drugs or hospitalization in the last six months	153	38.5	1	1.9

Clinical-Functional Vulnerability Indicators	Evaluator A		Evaluator B		Agreement percentage	Kappa coefficient

	n	%	n	%
Regular or bad self-perception of health	5	9.6	10	19.2	90.4	0.62
Functional disabilities – instrumental ADLs
Stopped, for health or physical condition...
doing shopping	1	1.9	1	1.9	100	1.00
controlling money/expenditures/paying bills	1	1.9	1	1.9	100	1.00
doing small domestic chores	1	1.9	1	1.9	100	1.00
Basic ADL: do not bath alone	1	1.9	1	1.9	100	1.00
Cognition
A relative or friend mentioned forgetfulness	9	17.3	5	9.6	92.3	0.67
Worsening of forgetfulness in the last months^b	1	11.1^a	2	40.0^a	98.1	0.66
Forgetfulness preventing the performance of some daily activity^b	0	0^a	0	0^a	100	NE
Mood
Dismay/Sadness/Hopelessness in the last month	5	9.6	2	3.9	94.2	0.55
Loss of interest or pleasure, in the last month, in previously enjoyable activities	1	1.9	2	3.9	98.1	0.66
Mobility: reach, graspingness, and pincer grip
Inability to raise the arm above shoulder level	0	0	0	0	100	NE
Inability to handle or hold small objects	0	0		0	100	NE
Aerobic and muscle capacity: Unintentional weight loss^c or BMI < 22 Kg/m² or calf circumference < 31 cm or time during the gait speed test from 4 min > 5 sec.	2	3.9	3	5.8	98.1	0.79
Gait
Two or more falls in the last year	4	7.7	4	7.7	100	1.00
Walking difficulties preventing to perform some daily activity	1	1.9	1	1.9	100	1.00
Sphincteral incontinence: involuntary loss of urine or feces	8	15.4	9	17.3	94.2	0.79
Communication
Vision problems that may prevent the performance of some daily activity^d	0	0	1	1.9	98.1	NE
Hearing problems that may prevent the performance of some daily activity^e	1	1.9	1	1.9	100	1.00
Comorbidities: Five or more chronic diseases or daily use of five or more different drugs or hospitalization in the last six months	0	0	1	1.9	98.1	NE

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E-mail: revsp@usp.br

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[1] Correspondence: Edgar Nunes de Moraes. Instituto Jenny de Andrade Faria. Alameda Vereador Álvaro Celso, 117 Sala 116 Santa Efigênia 30150-260 Belo Horizonte, MG, Brasil. E-mail: edgarnmoraes@gmail.com