CROSS-CULTURAL ADAPTATION AND VALIDITY OF THE “ EDMONTON FRAIL SCALE – EFS ” IN A BRAZILIAN ELDERLY SAMPLE

This study aimed to assess the cross-cultural adaptation of the Edmonton Frail Scale (EFS) and its validity in a Brazilian elderly sample. Translation and back-translation were performed, as well as discussion with professionals and elderly for conceptual equivalence, semantic validation and pre-test of the scale. The scale was applied to 137 elderly aged 65 years or older who lived in the community. In the know-groups validation of the frailty diagnosis between gender, age and cognitive deficit, elder elderly, female and with a cognitive deficit scored higher on the frailty diagnosis. A negative convergent correlation was found between the EFS and the Functional Independence Measure (FIM) (-0.53, p< 0.01) and the total score of the Mini-Mental State Examination (MMSE) (-0.60, p< 0.01). The watch test presented high sensitivity and low specificity levels. The Portuguese version of the EFS was considered valid in the study sample.


INTRODUCTION
Frailty among elderly people has emerged as an important concept in gerontology and geriatric.
It is mentioned as a significant risk factor for falls, disability, hospitalization and death in this population (1) .The theme has received little attention from Brazilian and international researchers, however, and no scientific consensus has been reached yet on its definition and indicators.
Frailty can manifest itself in people of all ages, including the elderly.It should not be considered a synonym of old age, however.Nowadays, it has been strongly considered a multidimensional syndrome, involving different factors: biological, physical, cognitive, social, economic and environmental (2)(3) .It is a type of syndrome that can be avoided when identified at an early stage, or at least delayed through interventions based on its indicators (4) .
Two main branches of frailty studies exist in international literature, represented by two research groups: one in the United States and another in Canada.The group established in Canada, the Canadian Initiative on Frailty and Aging (CIF-A), collaborates with some European countries, Israel and Japan.It started in 2002 and specialized research has been performed (5)   .Canadian participants in this group have studied a clinical proposal to detect frailty in elderly people, called the Edmonton Frail Scale (EFS) (3) .It has been validated and is considered reliable for routine use, even by non-specialists in geriatrics and gerontology.Its authors believe it is a more complete clinical proposal to detect frailty in elderly people, which is easy to handle and apply.
They also believe it is a broader scale as, in their opinion, cognition, mood and social support aspects can also be considered indicators of frailty in the elderly (3) .
During multidimensional assessment of the

CASES AND METHODS
The EFS is a scale to assess frailty in the The cultural adaptation was performed in line with the theoretical reference framewok by Guillemin, Bombardier and Beaton (6) .The order of phases was modified as proposed by Ferrer (7) , modifications that have been used in Brazilian research (8)(9)(10)    The convergence between both constructs was quantified through Spearman's correlation coefficient, illustrated in Table 3.A negative correlation was found between the EFS and FIM scores, as both are inversely ordered.
According to a classification recommended by literature (11) , the correlation between the frailty diagnosis and the global and motor FIM scores is moderate and negative, whereas a weak and negative correlation was found with cognitive FIM.All correlations were statistically significant (p<0.01).
The negative and moderate (11) correlation was maintained when analyzing the correlation between gross functional dependence and frailty scores, using Spearman's correlation coefficient, with statistical significance (-0.53, p<0.01).Applying Spearman's correlation coefficient, a negative correlation was found between functional independence on the EFS and FIM scores (-0.57, p<0.01).Results found when correlating the EFS with the gross MMSE score indicated a negative and weak correlation between the scales (-0.607).In this case, once again, adequate negative convergent validity predominant, and all correlations were statistically significant (p<0.01).
In this study, the sensitivity and specificity of the EFS clock test (cognitive dimension) were also calculated as a measure of criterion validity for a specific item.Sensitivity corresponded to 82.6% and specificity 36.9%.

DISCUSSION
Analyzing whether the existence or not of a cognitive deficit was correlated with the frailty diagnosis, it was verified that most elderly people without a cognitive deficit are considered as 'no frailty'.Hence, it can be considered that elderly patients with severe frailty have a cognitive deficit.Chronic diseases causing cognitive and mental disability are more strongly associated with frailty in the elderly, which is considered a syndrome that, among other causes, can be provoked by organic s y s t e m d e f i c i e n c y, i n c l u d i n g t h e c o g n i t i v e system (12) .
As to gender, women were considered more fragile than men.This fact needs further study, as the sample consists of women who are older than the men (Mann-Whitney test, discussed above, p=0.044).
However, frailty could be a characteristic of female elderly.In a research by Cardiovascular Health Study, prevalence of frailty in the elderly population was identified at 6.9%, and associations were found with some variables, including the female gender (13) .Many studies on falls from own height among elderly patients indicate that falls are more frequent among women.For some authors, the cause for these higher frequency levels is related to the fact that women are older and more fragile than men (14-15)   .Table 1 shows that most elderly diagnosed as "no frailty" are between 65 and 79 years of age.According to some authors, frailty can be a characteristic of people aged 80 years or older (16) .
During the validation of the original scale, the authors (3)

(
SPSS) software, version 15.0, was used for the random selection of this sample, based on a random number generator.Data were collected by interviewers whom the project advisor and researcher had trained, wearing a uniform and properly identified with a badge.They interviewed the elderly at their homes, using an instrument with the following information: sociodemographic data, cognitive assessment (MMSE) -functional independence (FIM) and frailty (Edmonton Frail Scale -EFS).Before the start of the interviews, the free and informed consent term was read to the elderly and/or caregiver to obtain their signature and authorization.Data were inserted in EXCEL, and a database was elaborated, using the double-entry (typing) validation technique.After typing and verifying data consistency, data were imported and analyzed in SPSS 15.0.To analyze the construct validity of the EFS, S p e a r m a n ' s n o n -p a r a m e t r i c r a n k c o r r e l a t i o n coefficient was calculated, between the frailty diagnosis and the gross MMSE score and the FIM American translators who have lived in Brazil for several years received the consensus version in Portuguese.They were not informed about the study objectives and did not know the original version of the scale.After the translations were done, two back- genders (three women and three men), randomly selected, complying with strict ethical guidelines.In this phase, the version applied to the elderly was not changed, as both the elderly and/or their caregivers considered they could understand it well and suggested no modifications.Later, for the pretest, the scale was applied to 40 elderly living in the community.These were selected in accordance with the criterion established for this research and specified further ahead, but were not included in the validity assessment of the scale.Like in semantic analysis, no scale items needed alterations and the interviewees understood the scale well, resulting in the final translated version.After performing the pretest and determining the final version of the scale, it was applied to a sample of elderly for validity analysis.This research, which is part of the project "Living and health conditions of elderly in Ribeirão Preto, São Paulo" was carried out in the urban area of Ribeirão Preto, São Paulo State, process was started.As a form of prevention in case of refusals or no answers, 993 people were randomly selected.This figure resulted from a correction for a response rate of 80%. a : ICC=0.90 and H 0 : ICC=0.8, and two evaluators.The size of this sample was determined at 109 elderly.Considering 20% of losses, the sample need of 137 elderly was found for reliability tests.In the end, the sampling criterion of reliability was used, as that was the largest sample size demanded in this research.Statistical Package for the Social Science

Table 1 -
Results of association tests between gender, age, cognitive deficit and frailty diagnosis variables.
diagnosis.Known-groups validation was also carried out, using Mann-Whitney's non-parametric test of the frailty diagnosis between gender, age and cognitive deficit.In this study, the sensitivity and
used Pearson's coefficient for analysis, with a significant correlation between EFS and age (r=0.27 and p= 0.015) and number of drugs (r=0.34 and p<0.001), but not in relation to gender (r=0.05 and p=0.647).Rev