Validation of a Record-based Frailty Assessment According to the Multidimensional Prognostic Index
Conditions: Frail Elderly Syndrome
Sponsor: University of Aarhus

 
Validation of a 
record-based frailty 
assessment 
according to the 
Multidimensional 
Prognostic Index  
 
 
Troels Kjærskov Hansen 
Aarhus University Hospital 
January 30th, 2019 
 

Validation of a record-based frailty assessment according to the Multidimensional Prognostic Index  
 1 
 
Validation of a record-based frailty assessment according to the 
Multidimensional Prognostic Index 
 
Background 
Various phenotype and cumulative frailty assessment tools have been developed and compared in research (1). For use in an in-
hospital setting, a cumulative and graded frailty assessment method is preferred in order to identify subgroups of patients at risk of 
adverse events during discharge and transition to primary care. Comprehensive Geriatric Assessment (CGA) is the gold standard 
to assess frailty (2). Most medical wards have limited access to specialized geriatric team support capable of performing CGA. 
Thus in these wards there is a need for a CGA based instrument to identify the frail patients and to quantify the level of frailty. 
The Multidimensional Prognostic Index (MPI) (3,4) is based on CGA and is a comprehensive cumulative deficit frailty 
assessment tool validated in a Danish geriatric department (5). MPI is fully applicable in the everyday clinical work and supplies 
useful information to clinicians. It can predict readmission and death (5), and it is well-suited to assess the degree of frailty (1,6). 
Enabling identification of patients at risk of adverse events facilitates targeting of the interventions in order to improve patient 
outcomes. The MPI is a bedside assessment. However, in observational record-based research the patient is not accessible for the 
researcher. To assess and identify hospitalized frail patients retrospectively for clinical research, a valid record-based frailty 
assessment method is needed. 
Objectives  
The aim of this study is to compare the accuracy of a record-based MPI assessment with a bedside performed MPI assessment in 
order to use the record-based MPI when access to bedside MPI is impossible.  
Hypothesis 
There is a high correlation (≥ 70%) between the bedside MPI sum score and the record-based MPI sum score in 75+ year older 
hospitalized patients. 
 
Materials and methods 
This validation study is performed in a paired design with comparison of the bedside MPI compared to a record-based MPI of the 
same hospitalized patient at the same day. 
Source of data 
Bedside MPI:  
The MPI screening tool for bedside use has been modified and validated as described by Gregersen et al. (5). The original MPI 
tool (3) consists of a combined score of eight items: co-habitation status, number of drugs used, activities of daily living (ADL) 
and instrumental activities of daily living (I-ADL), cognitive status, risk of pressure sores, morbidity and nutritional risk. In this 
study, the bedside MPI will be calculated using the following eight items: co-habitation status, number of drugs used, ADL and I-
ADL by Functional Recovery Score (FRS), cognitive status by Short Portable Mental Status Questionnaire (SPMSQ), risk of 
pressure sores by Exton Smith Scale (ESS), morbidity by Cumulative Illness Rating Scale Geriatrics (CIRS-G), and nutritional 
risk by the Mini Nutritional Assessment Short Form (MNA-SF). All items except the CIRS-G will be assessed by a Research 
Assistant.  
Record-based MPI: 
The Danish civil registration register, the hospital medical record used in Central Denmark Region, and the community nurse 
medical chart are all linked in the Columna Clinical information system (Systematic) used in all hospitals in Central Denmark 
Region. Information on all eight MPI items needed to calculate the sum score with the exception of SPMSQ and BMI in the 
MNA-SF can be assessed through the clinical information system and without direct bedside access to the patient. The record-
based MPI screening tool has been customized to these minor limitations (See Appendix A: Record-based MPI sum score and 
frailty level).  
Fifty unique patients are needed in this validation study. They will all be assessed by both a record-based MPI performed by two 
independent raters (a Research Assistant and a PhD student), and by bedside MPI performed by a skilled physiotherapist or 
occupational therapist (see Fig. 1: Record-based and bedside MPI-screening). All raters will be blinded to the screening results. 
Enrollment to the MPI screening is performed during daytime on weekdays by the Research Assistant. The CIRS-G used in both 
methods will be calculated by the Research Assistant prior to the record based MPI-screening. The record-based MPI screening 
will be performed before the bedside MPI screening, using only the medical record information accessible at the time of screening 

Validation of a record-based frailty assessment according to the Multidimensional Prognostic Index  
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as described in Appendix A. The inclusion takes place from December 4th, 2018 until the total of 50 patients has been reached. 
The inclusion will be paused during weekends and holidays. 
Patients 
The study group comprises medical patients acutely admitted to the Department of Cardiology (DC), and the Department of 
Infectious Diseases (DID), Aarhus University Hospital (AUH). Participants can only be included once. 
 
Inclusion criteria: 
- 
Aged 75 years or older 
- 
Living within the municipality of Aarhus 
 
Exclusion criteria: 
- 
Included in any other kind of follow-up schemes 
- 
Already included in this study 
- 
Declared terminally ill or undergoing palliative care at admission 
- 
Admitted from one specific temporary nursing home with geriatric medical assistance (Vikærgården) 
- 
Discharge or transfer to another department, including hospice 
- 
The patient does not want to participate in the MPI-screening process 
 
Statistical analysis 
Reasonable precision for estimates of reliability requires at least 50 study participants (7). The bedside MPI serves as a gold 
standard and will be held up against the record-based MPI. The relative difference between the two measurements’ sumscores is 
calculated as an Intraclass Correlation Coefficient (ICC). It is recommended that the ICC exceeds 70% in order to be regarded as 
acceptable (8). This method is controlled by calculating the correlation between the difference and the average by using the 
Pearson’s statistics. Assumption of independence is examined in a Bland-Altman plot and normal distribution of the differences 
will be checked in a QQ plot. Limits of agreement are prediction intervals for the difference and will be presented in a figure. The 
within-subject random variation (standard error of measurement) and the systematic change of the mean will be calculated. Also, 
the inter-rater reliability of two raters using the record-based MPI will be examined in the same way. We will examine how 
consistent the results are for the each of the eight different items and for the construct within the measures. The internal 
consistency is analyzed by Cronbach’s Alpha. Researchers have proposed that the minimum item-total correlation should be 0.20 
(9). Data are registered in REDCap and exported to STATA version 15 for the statistical calculations. 
 
Perspectives  
This study may prove that retrospective, record-based MPI frailty assessment is a valid way to assess frailty for scientific use, 
compared to bedside performed MPI, thereby enabling retrospective inclusion of control group patients in larger scale studies. 
Ethics 
The study has been approved as a quality development project by the Regional Research Ethics Committee, Central Denmark 
Region (journal no. 197/2017), thereby no patient consent form is needed, and further referral to the committee not required. No 
patient will receive less than usual care, no extra treatment or examination will be applied, and no patient will be exposed to any 
additional risk because of the study. Participants may decline participation at any point. The project, which is a part of the national 
rate adjustment pool-project "Early post-discharge follow-up of the frail elderly – a intersectoral effort" in the Central Denmark 
Region, is approved by the Danish Data Protection Agency (journal no. 2012-58-006). 
 

Validation of a record-based frailty assessment according to the Multidimensional Prognostic Index  
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APPENDIX A: Record-based MPI sum score and frailty level 
 
The bedside-assessment of MPI frailty level has been validated and slightly modified, and is performed as described by Gregersen 
et al. (5). The record-based MPI is a little further revised, since some information is not directly achievable or even unachievable 
in the medical records. The record-based assessment is made using the medical record information obtained from the municipality 
nurses and home care staff at admission and information provided by physiotherapists, nurses, occupational therapists, home care 
staff, municipality nurses, social workers and doctors during admission. In case of divergent information, the most recent 
information is considered right. In case of lack of information on the separate items, values are estimated based on the overall 
impression after reading the medical record. 
 
Co-habitation status: is always provided 
Number of drugs: is always obtainable 
FRS-ADL: some values are estimated based on the overall impression after reading the medical record. If no information at all is 
obtainable from the medical record, the patient is considered self-sufficient. 
FRS-I-ADL: some values are estimated based on the overall impression after reading the medical record. If no information at all is 
obtainable from the medical record, the patient is considered self-sufficient. 
SPMSQ: Since no testing can be performed, the SPMSQ is by default 3, unless the patient is described as delirious, confused or in 
other ways unable to answer the questions. If the patient has been diagnosed with any degree of dementia the score is 10 points. 
ESS: if no information is obtainable, the patient is considered alert, mobilized and continent.  
CIRS-G: is always obtainable 
MNA-SF: is modified with regards to neuropsychological problems and with regards to Body Mass Index (BMI) as described 
below, since the information is often unavailable or indistinctly described in the medical record. 
 
Modified SPMSQ:  
Default (no testing possible) 
3 points 
Delirium, confusion or in other way unable to answer 
questions 
5 points 
Diagnosed dementia  
10 points 
 
 
Modified MNA-SF: 
 
Point 
A Has food intake declined over the past three months 
due to loss of appetite, digestive problems, chewing or 
swallowing difficulties?  
0 = Severe decrease in food intake  
1 = Moderate decrease in food intake  
2 = No decrease in food intake 
 
B Weight loss during the last 3 months?  
0 = Weight loss greater than 3 kg (6.6 pounds)  
1 = Does not know 
2 = Weight loss between 1 and 3 kg (2.2 and 6.6 pounds) 
3 = No weight loss 
 
C Mobility 
0 = Bed or chair bound  
1 = Able to get out of bed/chair, but does not go out  
2 = Goes out 
 
D Psychological stress or acute disease 
0 (all hospitalized patients) 
E Neuropsychological problems:  
0 = Severe dementia or depression (diagnosed 
dementia, mild or severe; or diagnosed with 
depression, moderate or severe; or treated with anti-
depressants) 1 = Mild dementia (diagnosed with mild 
cognitive impairment or diagnosed dementia of mild 
stage; diagnosed mild depression (not treated with 
anti-depressants); described some degree of cognitive 
impairment, but undiagnosed 2 = No psychological 
problems 
 
F Estimated BMI 
0 point if BMI <19, or if patient is described as 
underweight, cachectic, malnourished or as suffering 
from sarcopenia or atrophy of the muscles.  
1 point if BMI between 19 and 21, or if state of 
 

Validation of a record-based frailty assessment according to the Multidimensional Prognostic Index  
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nutrition is not described.  
2 points if BMI between 21 and 23, or described as of 
normal weight or well nourished. 
3 points if BMI above 23 or described as overweight or 
obese.  
Score: (max 14 points)  
12-14 points: Normal nutritional status  
8-11 points: At risk of malnutrition  
0-7 points: Malnourished 
 
 
 
Record-based MPI sum score conversion table: 
 
low (=0) 
moderate (=0,5) 
severe (=1) 
Co-habitation 
With relative 
institution 
alone 
Number of drugs 
0-3 
4-7 
8 or more 
FRS (ADL) 
77-60 
59-37 
36-0 
FRS (I-ADL) (modified) 
19-13 
12-9 
8-0 
SPMSQ  
3 
5 
10 
ESS 
16-13 
12-9 
8-4 
CIRS-G 
0 
1-2 
3 or more 
MNA-SF (modified) 
12-14 
8-11 
0-7 
SUBTOTAL 
0 
(0-4) 
(0-8) 
TOTAL 
X 
X 
(0-8) 
Record based MPI sum 
score = TOTAL divided by 
8 
X 
X 
(0-1) 
 
Sum score to MPI frailty level conversion table: 
Sum score 
0,0-0,33 
0,33 – 0,66 
0,66 – 1,0 
Frailty level 
1 
2 
3 
 

Validation of a record-based frailty assessment according to the Multidimensional Prognostic Index  
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FIG. 1: Record-based and bedside MPI-screening  
 
Department of Cardiology (DC), and the Department of Infectious Diseases (DID), Aarhus University Hospital (AUH) 
All consecutively discharged, acutely admitted patients aged +75 years of age 
↓ 
Living within Aarhus Municipality 
↓ 
Receiving daily care, or 
CCI ≥ 1 
↓ 
Daily list of patients 
↓ 
CIRS-G 
↓ 
Record-based MPI made by PhD student and by Research Assistant (both blinded) 
↓ 
Bedside MPI made by physiotherapist or occupational therapist (blinded to the above assessment) 
↓ 
Inclusion and frailty assessment continues until at total number of 50 patients has been reached. 
 
 
 
 
 
 

Validation of a record-based frailty assessment according to the Multidimensional Prognostic Index  
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