ORIGINAL INVESTIGATION

Comparison of 2 Frailty Indexes

for Prediction of Falls, Disability,
Fractures, and Death in Older Women
Kristine E. Ensrud, MD, MPH; Susan K. Ewing, MS; Brent C. Taylor, PhD; Howard A. Fink, MD, MPH;
Peggy M. Cawthon, PhD; Katie L. Stone, PhD; Teresa A. Hillier, MD, MS; Jane A. Cauley, DrPH;
Marc C. Hochberg, MD; Nicolas Rodondi, MD, MAS; J. Kathleen Tracy, PhD; Steven R. Cummings, MD;
for the Study of Osteoporotic Fractures Research Group

Background: Frailty, as defined by the index derived

from the Cardiovascular Health Study (CHS index), predicts risk of adverse outcomes in older adults. Use of this
index, however, is impractical in clinical practice.
Methods: We conducted a prospective cohort study in
6701 women 69 years or older to compare the predictive validity of a simple frailty index with the components of weight loss, inability to rise from a chair 5 times
without using arms, and reduced energy level (Study of
Osteoporotic Fractures [SOF index]) with that of the CHS
index with the components of unintentional weight loss,
poor grip strength, reduced energy level, slow walking
speed, and low level of physical activity. Women were
classified as robust, of intermediate status, or frail using
each index. Falls were reported every 4 months for 1 year.
Disability (1 new impairment in performing instrumental activities of daily living) was ascertained at 412
years, and fractures and deaths were ascertained during
9 years of follow-up. Area under the curve (AUC) statistics from receiver operating characteristic curve analysis and 2 log likelihood statistics were compared for models containing the CHS index vs the SOF index.

Author Affiliations are listed at

the end of this article.
Group Information: A list of
the Study of Osteoporotic
Fractures Research Group was
published in Arch Intern Med.
2007;167(2):138.

Results: Increasing evidence of frailty as defined by either

the CHS index or the SOF index was similarly associated with an increased risk of adverse outcomes. Frail
women had a higher age-adjusted risk of recurrent falls
(odds ratio, 2.4), disability (odds ratio, 2.2-2.8), nonspine fracture (hazard ratio, 1.4-1.5), hip fracture (hazard ratio, 1.7-1.8), and death (hazard ratio, 2.4-2.7)
(P .001 for all models). The AUC comparisons revealed no differences between models with the CHS index vs the SOF index in discriminating falls (AUC=0.61
for both models; P=.66), disability (AUC=0.64; P=.23),
nonspine fracture (AUC = 0.55; P = .80), hip fracture
(AUC=0.63; P=.64), or death (AUC=0.72; P=.10). Results were similar when 2 log likelihood statistics were
compared.
Conclusion: The simple SOF index predicts risk of falls,

disability, fracture, and death as well as the more complex CHS index and may provide a useful definition of
frailty to identify older women at risk of adverse health
outcomes in clinical practice.
Arch Intern Med. 2008;168(4):382-389

RAILTY IS DEFINED VARIABLY

because many factors have

been reported to reflect
frailty in older adults1 and it
has not yet emerged as a discrete clinical syndrome.2,3 Despite these
limitations, it is recognized that older persons characterized as frail have a higher
risk of adverse health outcomes that is not
entirely explained by advanced age, poorer
functional status, or greater prevalence of
comorbidities.4
In an attempt to operationalize and
standardize the definition of frailty, Fried
et al,5 using data from the Cardiovascular
Health Study (CHS), proposed a phenotype of frailty (CHS index) in which 3 or
more of the following 5 components were
present: unintentional weight loss, self-

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382

reported reduced energy level, reduced

grip strength, slow walking speed, and low
level of physical activity. Frailty as defined by the CHS index was associated with
an increased risk of falls, hospitalization,
disability, and death. Subsequently, the
predictive validity of the CHS index has
been confirmed in other cohorts.6-10 It has
been suggested that the CHS index be used
to screen older persons for frailty.5
However, assessment of frailty using the
CHS index is impractical in the clinical setting. Ascertainment of 3 of its components (grip strength, walking speed, and
physical activity) requires knowledge of the
underlying distribution of the measure in
a given population and identification of
these components also depends on sex and
body size. Components including physi-

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cal activity and timed walks are often infeasible to evaluate in the clinic because of tight schedules and space constraints. Unintentional weight loss is a component of the
CHS frailty phenotype; however, reporting of intent to lose
weight is not straightforward because knowledge of the
direction of weight change may bias patient responses to
a question about intent. In addition, both intentional and
unintentional weight loss have been associated with an increased risk of disease in older persons.11-14
Based on the physiologic domains most frequently cited
in the frailty literature,15,16 findings from previous studies that evaluated the predictive validity of individual components,11,12,17-21 and suitability of assessment of components in a busy clinical practice setting, we proposed a
simple frailty index using 3 components: weight loss, the
subjects inability to rise from a chair 5 times without using
her arms, and reduced energy level (Study of Osteoporotic Fractures [SOF] index). We used data collected in
the SOF to compare the value of the SOF index with that
of the more complex CHS index for prediction of falls,
disability, fractures, and death in a cohort of 6701 community-dwelling women 69 years or older.
METHODS

PARTICIPANTS
From September 1986 to October 1988, a total of 9704 women
aged at least 65 years were recruited for participation in the baseline examination of the prospective SOF. Women were recruited from population-based listings in 4 areas of the United
States (Baltimore County, Maryland; Minneapolis, Minnesota; Portland, Oregon; and the Monongahela Valley, Pennsylvania).22 Black women were originally excluded from the SOF
because they have a low incidence of hip fracture. In addition,
women were excluded if they were unable to walk without assistance or had a history of bilateral hip replacement.
All surviving participants were invited to undergo a fourth
examination between August 1992 and July 1994. A total of
8412 women (97% of the survivors as of July 31, 1994) completed at least the questionnaire component of this examination. Of these, 6701 women provided data for at least 2 components of the 3 frailty criteria in the SOF index and for at least
3 components of the 5 frailty criteria in the CHS index and are
the subject of this analysis. The institutional review board at
each center approved the study protocol, and written informed consent was obtained from all participants.

full of energy?).25 Cognitive function was assessed with a modified version of the Mini-Mental State Examination26 with a maximum score of 26. To assess functional disability, women were
asked whether they had any difficulty performing any of 5 instrumental activities of daily living (IADL).27 Tests of physical
function included grip strength using a handheld dynamometer ( Jamar; Sammons Preston Rolyan, Bolingbrook, Illinois),
walking speed (time in seconds to walk 6 m at usual pace), and
the subjects ability to rise from a chair 5 times without using
her arms. Body weight was recorded using a balance beam scale
at the third and fourth examinations. Height was measured using
a standard held-expiration technique with a wall-mounted stadiometer (Harpenden; Holtain Ltd, Crymych, Wales). Height and
weight were used to calculate a standard body mass index (calculated as weight in kilograms divided by height in meters
squared). Bone mineral density of the proximal femur was measured using dual-energy x-ray absorptiometry (QDR 1000 densitometer; Hologic Inc, Waltham, Massachusetts).

SOF FRAILTY INDEX

Frailty defined by the SOF index was identified by the presence
of 2 or more of the following 3 components at the fourth examination: (1) weight loss (irrespective of intent to lose weight) of
5% or more between the third and fourth examinations (mean
[SD] years between examinations, 2.0 [0.3]); (2) the subjects
inability to rise from a chair 5 times without using her arms; and
(3) reduced energy level, as identified by an answer of no to
the question Do you feel full of energy? on the Geriatric Depression Scale.25 Women having none of these components were
considered to be robust, and those having 1 component were considered to be in an intermediate or prefrail stage.

CHS FRAILTY INDEX

Frailty defined by the CHS index as proposed by Fried et al5 was
identified by the presence of 3 or more of the following 5 components at the fourth examination: (1) unintentional weight loss
of 5% or more between the third and fourth examinations (mean
[SD] years between examinations, 2.0 [0.3]); (2) weakness, as
identified by grip strength in the lowest quintile stratified by body
mass index quartile; (3) reduced energy level, as identified by
an answer of no to the question Do you feel full of energy?
on the Geriatric Depression Scale25 (4) slowness, as identified
by a walking speed in the lowest quintile stratified by median
standing height; and (5) low physical activity level, as identified
by a weighted score of kilocalories expended per week in the lowest quintile. Women having none of these components were considered to be robust, and those having 1 or 2 components were
considered to be in an intermediate or prefrail stage.

MEASUREMENTS
Participants completed a questionnaire and were interviewed at
the fourth examination and asked about health status, educational achievement, smoking history, intent to lose weight, and
falls during the previous year. A selected medical history was obtained that included a history of physician diagnosis of fracture
since the age of 50 years, stroke, cancer excluding skin cancer,
dementia, hypertension, parkinsonism, diabetes mellitus, coronary heart disease, and chronic obstructive lung disease. Participants were asked to bring all prescription and nonprescription medications, including estrogen preparations, to the clinic
for verification of use. Physical activity was assessed using a modified version of the Harvard Alumni Questionnaire23,24 and was
expressed as a weighted score of kilocalories expended per week.
Depressive symptoms were evaluated using the 15-item Geriatric Depression Scale (which includes the question Do you feel

ASCERTAINMENT OF FALLS, DISABILITY,

FRACTURES, AND DEATH
After the fourth examination, we contacted participants about
falls and fractures every 4 months by postcard or telephone.
All falls reported on the first 3 postcards were included in the
falls analysis (mean [SD] 11.9 [0.9] months) after the fourth
examination (covering approximately 1 year). More than 98%
of these follow-up contacts were completed. Functional status
was assessed at the fourth examination and, on average, 412
years later at the sixth examination; incident disability was defined as 1 or more new impairment(s) in IADL. Fractures were
confirmed by review of radiographic reports. All first hip fractures occurring after the fourth examination and before January 31, 2006, were included in analyses examining the association between frailty and risk of hip fracture. Any nonspine

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Table 1. Characteristics of 6701 Participants

Patients,
No. (%)

Variable
Age, mean (SD), y
Frailty status by CHS index
Robust
Intermediate
Frail
Frailty status by SOF index
Robust
Intermediate
Frail
Individual CHS index components
Unintentional weight loss a
Weakness
Reduced energy level
Slowness
Low physical activity level
Individual SOF index components
Weight loss b
Inability to rise from chair c
Reduced energy level
2 Falls during first year of study
1 New IADL impairments d
1 Incident nonspine fracture
First hip fracture
Death

76.7 (4.8)
2462 (37)
3152 (47)
1087 (16)
3117 (47)
2440 (36)
1144 (17)
783 (12)
1303 (20)
2880 (43)
1332 (20)
1211 (18)
1017 (15)
779 (12)
2880 (43)
734 (11)
1912 (35)
2200 (33)
707 (11)
2751 (41)

Abbreviations: CHS, Cardiovascular Health Study; IADL, instrumental

activities of daily living; SOF, Study of Osteoporotic Fractures.
a Unintentional weight loss of 5% or more during the 2 years before the
examination.
b Weight loss of 5% or more during the 2 years before the examination.
c The subjects inability to rise from a chair 5 times without using her
arms.
d A total of 5386 women completed the initial and follow-up IADL
assessments.

fractures during this period were included in the analyses examining the relationship between frailty and risk of any nonspine fracture. Mean (SD) follow-up was 9.3 (3.5) years for hip
fracture and 7.9 (4.0) years for any nonspine fracture. We were
able to complete more than 95% of the triannual follow-up contacts about fracture status in surviving women. Deaths were
identified by contacts every 4 months and confirmed with death
certificates. Follow-up for vital status was 99% complete. Mean
(SD) follow-up for death was 9.6 (3.3) years.

STATISTICAL ANALYSIS
We used 2 tests of homogeneity, analyses of variance, and
Kruskal-Wallis tests to compare characteristics of participants
at the fourth examination by category of frailty according to
the SOF index. Logistic regression was used to analyze the association between frailty status as defined by SOF and CHS indexes and the odds of recurrent falls (2 falls vs 1 fall) in
the subsequent year and odds of disability after 412 years of follow-up. Cox proportional hazards models were used to analyze the associations between frailty status as defined by SOF
and CHS indexes and subsequent outcomes including any incident nonspine fracture, first hip fracture, and death. The relative risk (approximated as hazard ratios or odds ratios ) of each
outcome with 95% confidence intervals was estimated in women
categorized as having intermediate frailty status and those categorized as frail, using women who were categorized as robust
as the referent group. We also used logistic regression to examine receiver operating characteristic curves for each model

and calculated the area under the curve (AUC). All primary
analyses were adjusted for age alone because the objective was
to assess the utility of each frailty index as it might be used in
clinical practice to predict outcomes. Secondary analyses were
adjusted for additional factors previously identified in the cohort to predict the outcomes.
A bootstrap procedure28,29 was used to compare 2 log likelihood (2LL) model fit statistics for proportional hazards or
logistic regression models containing CHS index vs SOF index and to compare AUC statistics from logistic regression receiver operating characteristic curve analysis. The full study
population was sampled (with replacement) 1000 times. Each
bootstrap sample was fit to the 2 models being compared, and
the difference between the 2LL statistics and between AUC
statistics was calculated. The distribution of these observed
differences was used to make statistical inference about the likelihood that the 2LL statistics or AUC statistics from the 2 models were significantly different (P.05). Using the 10-fold crossvalidation procedure,30 results for the comparison of observed
AUC statistics between models with the CHS index and models with the SOF index were cross-validated (results not shown).
RESULTS

CHARACTERISTICS
OF THE STUDY POPULATION
Characteristics of the cohort of 6701 women (mean age,
76.7 years) are given in Table 1. With the CHS index,
16% were classified as frail (3 components), 47% as having intermediate status (1-2 components), and 37% as
robust (no components). With the SOF index, 17% of
women were classified as frail (2 components), 36%
as having intermediate status (1 component), and 47%
as robust (no components). Classification of frailty status using the indexes was concordant in 4965 women
(74%). The statistic was 0.59. The Spearman correlation between indexes was 0.75 (P .001). Characteristics of participants by category of frailty status as defined by the SOF index are given in Table 2.
During a mean follow-up of 11.9 months, 734 women
(11%) experienced 2 (recurrent) falls or more. At a mean
of 412 years later, 1912 women (35%) reported 1 or more
new IADL impairment(s) among the 5386 women with
IADL data at both examinations. During a mean follow-up ranging from 7.9 years (any nonspine fracture) to
9.3 years (hip fracture) to 9.6 years (death), 2200 women
(33%) experienced 1 or more nonspine fracture(s), including 707 women (11%) who sustained a first hip fracture, and 2751 women (41%) who died. Compared with
the 6701 women included in this analysis who provided
sufficient data on frailty components for calculation of the
frailty indexes, the 1711 women excluded from the analyses because of insufficient data were more likely to have
died during follow-up (55% vs 41%; P.001).
SOF INDEX VS CHS INDEX FOR PREDICTION
OF FALLS, DISABILITY, FRACTURES, AND DEATH
Increasing evidence of frailty as identified using the SOF
or CHS index was similarly associated with an increased
odds of 2 or more (recurrent) falls in the subsequent year

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Table 2. Characteristics of Participants by Category of Frailty Status as Defined by the SOF Index
Category of Frailty Status a
Variable
Age, mean (SD), y
Self-reported health status
Excellent or good
Fair
Poor or very poor
Smoking status
Current
Former
Never
Educational achievement, mean (SD), y
Current estrogen use
Any fracture since age 50 y
Selected medical conditions b
None
1-2
3
Any fall in previous year
Depressive symptoms
Geriatric Depression Scale score 0-15, mean (SD)
Cognitive function
Mini-Mental Status Examination score 0-26, mean (SD)
IADL impairments, range 0-5, mean (SD)
BMI, mean (SD)
Femoral neck BMD, mean (SD), g/cm2

Robust
(n = 3117)

Intermediate
(n = 2440)

Frail
(n = 1144)

75.8 (4.3)

76.8 (4.7)

79.1 (5.6)

.001

2903 (93)
200 (6)
14 (1)

1866 (76)
533 (22)
41 (2)

647 (57)
415 (36)
80 (7)

.001

147 (5)
1022 (33)
1912 (62)
12.8 (2.7)
564 (18)
1328 (43)

151 (6)
802 (33)
1463 (61)
12.8 (2.7)
451 (18)
1171 (48)

70 (6)
359 (32)
695 (62)
12.5 (2.9)
197 (17)
641 (56)

1318 (42)
1690 (54)
108 (3)
808 (26)

719 (29)
1507 (62)
213 (9)
774 (32)

245 (21)
693 (61)
205 (18)
451 (39)

0.7 (1.1)

2.5 (2.3)

3.7 (2.7)

.001

24.6 (1.7)
0.2 (0.7)
26.3 (4.4)
0.64 (0.11)

24.5 (1.9)
0.7 (1.1)
26.8 (4.8)
0.63 (0.12)

23.9 (2.4)
1.8 (1.7)
26.2 (5.4)
0.61 (0.13)

.001
.001
.001
.001

P Value

.12
.01
.66
.001
.001
.001

Abbreviations: BMD, bone mineral density; BMI, body mass index (calculated as weight in kilograms divided by height in meters squared); IADL, instrumental
activities of daily living; SOF, Study of Osteoporotic Fractures.
a Data are given as number (percentage) of patients unless otherwise specified.
a History of 1 or more selected medical conditions including stroke, cancer (excluding skin cancer), dementia, hypertension, parkinsonism, diabetes mellitus,
coronary heart disease, and chronic obstructive lung disease.

Table 3. Comparison of CHS vs SOF Indexes for Prediction of Recurrent Falls

Index of Frailty a

Patients With 2 Falls,

No. (%)

CHS index
Robust (n = 2402)
Intermediate (n=3082)
Frail (n = 1036)
SOF index
Robust (n = 3038)
Intermediate (n=2378)
Frail (n = 1104)

...
200 (8)
323 (10)
211 (20)
...
251 (8)
268 (11)
215 (19)

OR (95% CI) b
...
1 [Reference]
1.23 (1.02-1.48)
2.44 (1.95-3.04)
...
1 [Reference]
1.36 (1.14-1.63)
2.38 (1.94-2.92)

2LL (95% CI)

4478 c

(4272-4684)
...
...
...
4475 (4269-4682)
...
...
...

AUC (95% CI)

0.61 d (0.59-0.63)
...
...
...
0.61 (0.59-0.64)
...
...
...

Abbreviations: AUC, area under the curve; CHS, Cardiovascular Health Study; CI, confidence interval; 2LL, 2 log likelihood; OR, odds ratio; SOF, Study of
Osteoporotic Fractures; ellipses, not applicable.
a Among the 6701 women with data for both frailty indexes, 181 who did not provide fall information at follow-up contacts during the subsequent year were
excluded from this analysis.
b Adjusted for age.
c P = .89 for comparison of CHS index vs SOF index.
d P = .66 for comparison of CHS index vs SOF index.

(Table 3). Compared with robust women, women in the

intermediate group had a 1.2- to 1.4-fold age-adjusted increase in risk (P.04 for both models) and frail women
had a 2.4-fold increase in risk (P.001 for both models).
There was no difference in 2LL statistics between models (P=.89). Across a range of sensitivities and specificities, the receiver operating characteristic curves were es-

sentially superimposed for the model containing the SOF

index vs the model containing the CHS index (Figure, A).
Using either index, AUC statistics were essentially identical (P=.66 for comparison of AUC statistics).
The odds of incident disability (1 new IADL impairment) were greater with increasing evidence of frailty
using either the SOF or CHS index (Table 4). Com-

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Sensitivity, %

100

100

Recurrent falls

90

90

80

80

70

70

60

60

50

50

40

40
30

30
20

20

SOF index AUC, 0.61

CHS index AUC, 0.61

10

SOF index AUC, 0.64

CHS index AUC, 0.64

10
0

0
0

20

10

30

40

50

60

70

80

90

100

10

20

30

40

50

60

70

80

90

100

C
100

Sensitivity, %

Disability

100

Hip fracture

90

90

80

80

70

70

60

60

50

50

40

40

30

30

20

20

SOF index AUC, 0.63

CHS index AUC, 0.63

10

Death

SOF index AUC, 0.72

CHS index AUC, 0.72

10
0

0
0

10

20

30

40

50

60

70

80

90

100

10

20

30

40

50

60

70

80

90

100

1Specificity, %

1Specificity, %

Figure. Age-adjusted receiver operating characteristic curves for prediction of recurrent falls (A), disability (B), hip fracture (C), and death (D) with the Study of
Osteoporotic Fractures (SOF) and Cardiovascular Health Study (CHS) frailty indexes. The black diagonal line indicates a reference area under the curve (AUC) of
0.50 (no better than chance alone).

Table 4. Comparison of CHS vs SOF Indexes for Prediction of Disability

Index of Frailty a

Patients With 1 New IADL

Impairment, No. (%)

CHS index
Robust (n = 2186)
Intermediate (n=2551)
Frail (n = 649)
SOF index
Robust (n = 2701)
Intermediate (n=1959)
Frail (n = 726)

...
542 (25)
1023 (40)
347 (53)
...
736 (27)
821 (42)
355 (49)

OR (95% CI) b
...
1 [Reference]
1.89 (1.66-2.14)
2.79 (2.31-3.37)
...
1 [Reference]
1.84 (1.63-2.09)
2.17 (1.82-2.58)

2LL (95% CI)

6695 c

(6592-6798)
...
...
...
6719 (6617-6821)
...
...
...

AUC (95% CI)

0.64 d (0.63-0.66)
...
...
...
0.64 (0.62-0.65)
...
...
...

Abbreviations: AUC, area under the curve; CHS, Cardiovascular Health Study; CI, confidence interval; IADL, instrumental activities of daily living; 2LL, 2 log
likelihood; OR, odds ratio; SOF, Study of Osteoporotic Fractures; ellipses, not applicable.
a Among the 6701 women with data for both frailty indexes at the initial examination, 1315 who did not provide IADL information at the initial examination
(n = 11) or at 412-year follow-up (n=1304) were excluded from this analysis, including 792 women who died (n = 735) or terminated study participation (n=57) in
the interim period, 424 who did not provide IADL data at the follow-up examination, and 88 who were unable to attend the follow-up examination.
b Adjusted for age.
c P = .17 for comparison of CHS index vs SOF index.
d P = .23 for comparison of CHS index vs SOF index.

pared with robust women, women in the intermediate

group had an age-adjusted 1.8- to 1.9-fold increase in risk
(P.001 for both models) and frail women had a 2.2to 2.9-fold increase in risk (P .001 for both models).
Although the point estimates of the association were
higher in magnitude for the model with the CHS index,
the comparison between 2LL statistics did not reach sig-

nificance (P =.17) and there was no difference between

AUC statistics (P=.23) (Figure 1B).
Frailty as identified using either the SOF or CHS index
was also similarly related to an increased risk of incident
nonspine fracture (results not shown), including hip fracture (Table 5). After adjustment for age, women in the
intermediate group had a 1.3- to 1.4-fold increased risk of

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Table 5. Comparison of CHS vs SOF Indexes for Prediction of Hip Fracture

Index of Frailty a
CHS index
Robust (n = 2420)
Intermediate (n=3037)
Frail (n = 990)
SOF index
Robust (n = 3053)
Intermediate (n=2355)
Frail (n = 1039)

Patients With First Hip

Fracture, No. (%)

Age-Adjusted Rate
per 1000 Person-Years

HR (95% CI) b

2LL (95% CI)

AUC (95% CI)

...
207 (9)
361 (12)
139 (14)
...
278 (9)
275 (12)
154 (15)

...
9.6
12.7
15.8
...
10.2
12.8
16.4

...
1 [Reference]
1.38 (1.16-1.64)
1.71 (1.36-2.15)
...
1 [Reference]
1.31 (1.11-1.55)
1.79 (1.46-2.19)

11 711 c (10 865-12 557)

...
...
...
11 703 (10 857-12 549)
...
...
...

0.63 d (0.60-0.65)
...
...
...
0.63 (0.60-0.65)
...
...
...

Abbreviations: AUC, area under the curve; CHS, Cardiovascular Health Study; CI, confidence interval; HR, hazard ratio; 2LL, 2 log likelihood; SOF, Study of
Osteoporotic Fractures; ellipses, not applicable.
a Among the 6701 women with data for both frailty indexes, 254 were excluded from this analysis (234 women with previous hip fracture, 4 women with
incident traumatic hip fracture, and 16 women with unconfirmed hip fracture).
b Adjusted for age.
c P = .34 for comparison of CHS index vs SOF index.
d P = .64 for comparison of CHS index vs SOF index.

Table 6. Comparison of CHS vs SOF Indexes for Prediction of Death

No. of
Deaths (%)

Index of Frailty
CHS index
Robust (n = 2462)
Intermediate (n=3152)
Frail (n = 1087)
SOF index
Robust (n = 3117)
Intermediate (n=2440)
Frail (n = 1144)

...
673 (27)
1329 (42)
749 (69)
...
953 (31)
1050 (43)
748 (65)

Age-Adjusted Rate
per 1000 Person-Years
...
30.2
43.5
78.4
...
32.9
44.8
70.7

HR (95% CI) a
...
1 [Reference]
1.54 (1.40-1.69)
2.75 (2.46-3.07)
...
1 [Reference]
1.44 (1.32-1.57)
2.37 (2.14-2.61)

2LL (95% CI)

45 328 b

(44 073-46 585)

...
...
...
45 363 (44 107-46 618)
...
...
...

AUC (95% CI)

0.72 c (0.71-0.74)
...
...
...
0.72 (0.71-0.73)
...
...
...

Abbreviations: AUC, area under the curve; CHS, Cardiovascular Health Study; CI, confidence interval; HR, hazard ratio; 2LL, 2 log likelihood; SOF, Study of
Osteoporotic Fractures; ellipses, not applicable.
a Adjusted for age.
b P = .20 for comparison of CHS index vs SOF index.
c P = .10 for comparison of CHS index vs SOF index.

hip fracture (P.002 for both models) and a 1.2-fold increased risk of any nonspine fracture (P.002 for both
models), whereas frail women had a 1.7- to 1.8-fold increased risk of hip fracture (P.001 for both models) and
a 1.5-fold increased risk of any nonspine fracture (P.001
for both models). There was no difference in 2LL statistics between hip fracture models (P=.34) or nonspine fracture models (P=.95). In receiver operating characteristic
analyses, hip fracture models containing the SOF index performed similarly to those containing the CHS index (Figure, C) (P=.64 for comparison of AUC statistics). The AUC
statistics were lower, but similar using either index, for nonspine fracture models (AUC, 0.55 for both models; P=.80).
All-cause mortality rates were higher with increasing
evidence of frailty as identified using either the SOF or
CHS index (Table 6). Compared with robust women,
women in the intermediate group had an age-adjusted
1.4- to 1.5-fold increased risk of death (P.001 for both
models) and frail women had a 2.4- to 2.7-fold increased risk of death (P .001 for both models). Although the point estimates of the association were slightly
greater for the model with the CHS index, the comparison between 2LL statistics did not reach significance

(P=.20). Similarly, there was no difference between AUC

statistics (P=.10) for the 2 models (Figure, D).
For each outcome, the addition of multiple covariates (including health status; smoking history; educational achievement; estrogen use; history of fracture; history of selected medical conditions including stroke,
cancer (excluding skin cancer), dementia, hypertension, parkinsonism, diabetes mellitus, coronary heart disease, and chronic obstructive lung disease; history of falls
(models for fracture and death); depressive symptoms;
cognitive function; functional disability; body mass index; and femoral neck bone mineral density to the ageadjusted model resulted in a small to moderate improvement in the predictive accuracy of the model. However,
there was still no difference in 2LL statistics from multivariate models with the SOF index and those containing the CHS index. P values for 2LL comparisons were
0.38 (falls), 0.34 (disability), 0.62 (nonspine fracture),
0.92 (hip fracture), and 0.28 (death). Using either index, AUC statistics were almost identical for falls (AUC,
0.67 using the SOF index vs 0.68 using the CHS index;
P=.054), and there was no difference between multivariate models in discriminating disability (AUC, 0.68 using

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the SOF index vs 0.69 using the CHS index; P =.42), nonspine fracture (AUC, 0.65 for both models; P =.86), hip
fracture (AUC, 0.73 for both models; P= .96), or death
(AUC, 0.74 for both models; P = .17).
COMMENT

In this large cohort of community-dwelling older women,

assessment of frailty using the simple SOF index based
on 3 components (weight loss, the subjects inability to
rise from a chair 5 times without using her arms, and reduced energy level) and evaluation of frailty using the
more complex CHS index performed similarly in the prediction of risk of falls, disability, fracture, and death. These
findings suggest that the parsimonious SOF index provides a useful definition of frailty to identify high-risk
older women seen in clinical practice.
There is a pervasive belief that clinicians can easily discern whether an older patient is frail.31 However, there is
no uniformly accepted definition or official International
Classification of Diseases (ICD) diagnosis for frailty. The use
of the term frailty in clinical geriatric medicine typically
describes the presence of multisystem impairment and increasing vulnerability. Several instruments have been developed to operationalize the construct of frailty,15 including recent indexes based on clinical judgment,32 deficit
accumulation,33 and comprehensive geriatric assessment.34 The CHS index5 has been most extensively studied. The validity of the CHS index in predicting risk of adverse outcomes including functional impairment, falls,
hospitalization, fracture, and death has been corroborated in several cohorts of older adults.6-10 In addition, the
CHS index has been linked to specific alterations in physiologic factors providing evidence of multisystem impairment and biological and molecular pathways that may underlie the development of the clinical frailty syndrome.35-37
It has been suggested that the CHS index might serve as
the basis for screening older persons for frailty and risk of
frailty,5 be used to identify a target population for entry into
randomized trials evaluating interventions with the goal
of preventing or delaying functional decline and disability,15 and be integrated into the comprehensive care for older
women.38
We found that classification of frailty status using the
CHS and SOF indexes was concordant in 74% of participants. Thus, the SOF and CHS indexes similarly discriminate between groups of older women in identification of
frailty status. In addition, our results confirm the value of
the CHS index in screening older women for risk of falls,
disability, fracture, and death, with an AUC as high as 0.72
for death in age-adjusted models. However, we did not find
evidence that the prediction of these outcomes was better using the more complicated CHS index as compared
with the straightforward SOF index, which was parsimonious without substantial losses in its discriminative ability. Like the CHS index, the 3 components of the SOF index (weight loss, the subjects inability to rise from a chair
5 times without using her arms, and reduced energy level)
reflect impairment in 1 or more physiologic domains most
frequently cited in the frailty literature15,16: mobility, such
as lower-extremity performance and gait abnormalities;

muscle weakness; poor exercise tolerance including feelings of fatigue and exhaustion; unstable balance; and factors related to body composition such as weight loss, malnutrition, and sarcopenia. However, unlike for the CHS
index, the SOF criteria are not dependent on sex, body size,
underlying distribution of the measure in a population,
or ability to assess intent to lose weight, and are easily assessed and inexpensively obtained in a few minutes in the
clinical setting.
This study has many strengths, including its prospective design, comprehensive set of measurements, and duration and completeness of follow-up. To our knowledge, this is the first study to evaluate and compare the
overall predictive value of 2 frailty instruments. However, this study has several limitations. Participants were
older white women living in the community, and our findings may not be applicable to other population groups. Additional prospective studies are needed to confirm the predictive validity of the SOF index in other populations. While
prediction of all-cause mortality is of essential prognostic
importance in aged populations and disability, falls and
fractures are a common cause of morbidity in older
adults39,40; future studies should evaluate the ability of the
SOF index to predict other outcomes including hospitalization and institutionalization. Our findings indicate that
both the CHS and SOF indexes are limited in their ability
to discriminate falls, disability, and fracture. Neither index should be used as the sole tool for screening for risk
of these outcomes. However, the validity of these frailty
indexes in predicting hip and nonspine fractures was similar to that reported for other tools based on the use of clinical risk factors alone.41 These results may underestimate
the ability of the CHS and SOF indexes to predict death
because women excluded from the analyses owing to insufficient data on frailty components were more likely to
die during follow-up. The objective of this analysis was
to compare the ability of the SOF index with that of the
CHS index to predict adverse outcomes, and future studies are needed to examine whether the SOF index is useful in the longitudinal characterization of change in frailty
status across time. We compared the predictive ability of
the SOF index with that of the widely used CHS index;
however, several indexes of frailty have been proposed15,32-34 and our findings are not generalizable across
different frailty definitions.
The simple SOF index provides an operational definition of frailty that predicts risk of falls, disability, fracture,
and death as well as the more complicated CHS index. Thus,
the SOF index provides a useful phenotype of frailty to identify high-risk older women in clinical practice.
Accepted for Publication: September 17, 2007.
Author Affiliations: Center for Chronic Disease Outcomes Research, Veterans Affairs Medical Center, and Department of Medicine and Division of Epidemiology and
Community Health, University of Minnesota, Minneapolis (Drs Ensrud, Taylor, and Fink); Department of Epidemiology and Biostatistics, University of California, San Francisco (Ms Ewing), and Research Institute, California Pacific
Medical Center (Drs Cawthon, Stone, and Cummings), San
Francisco; Center for Health Research, Kaiser Permanente Northwest/Hawaii, Portland, Oregon (Dr Hillier);

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Department of Epidemiology, University of Pittsburgh,

Pittsburgh, Pennsylvania (Dr Cauley); Departments of
Medicine (Dr Hochberg) and Epidemiology (Dr Tracy),
University of Maryland, Baltimore; and University Outpatient Clinic, Department of Community Medicine and
Public Health, University of Lausanne, Lausanne, Switzerland (Dr Rodondi).
Corresponding Author: Kristine E. Ensrud, MD, MPH;
Center for Chronic Disease Outcomes Research, Veterans Affairs Medical Center, 1 Veterans Dr, General Internal Medicine (Mail Stop 111-0), Minneapolis, MN
55417 (ensru001@.umn.edu).
Author Contributions: Ms Ewing had full access to all the
data in the study and takes responsibility for the integrity
of the data and the accuracy of the data analyses. Study
concept and design: Ensrud and Cauley. Acquisition of data:
Ensrud, Hochberg, and Cummings. Analysis and interpretation of data: Ensrud, Ewing, Taylor, Fink, Cawthon, Stone,
Hillier, Cauley, Rodondi, and Tracy. Drafting of the manuscript: Ensrud and Cauley. Critical revision of the manuscript for important intellectual content: Ewing, Taylor, Fink,
Cawthon, Stone, Hillier, Cauley, Hochberg, Rodondi, Tracy,
and Cummings. Statistical analysis: Ewing, Taylor, Fink,
Stone, Rodondi, and Tracy. Obtained funding: Ensrud, Stone,
and Cummings. Administrative, technical, and material support: Cawthon. Study supervision: Ensrud and Stone.
Financial Disclosure: None reported.
Funding/Support: This study was supported in part by
Public Health Service research grants AG05407, AR35582,
AG05394 (Dr Ensrud), AR35584, AR35583 and AG08415
from the National Institutes of Health.
Role of the Sponsor: The National Insitutes of Health had
no role in the design and conduct of the study; in the collection, analysis, and interpretation of the data; or in the
preparation, review, or approval of the manuscript.
Additional Contributions: Kyle A. Moen assisted with
the manuscript and with the preparation and formatting of the tables and figure.
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