Validity and reliability of the Polish version of the Tilburg Frailty Indicator (TFI)

Abstract

Aim
The aim of this study was to assess the psychometric properties of the Polish version of the Tilburg Frailty Indicator (TFI), an instrument that identifies frailty in the elderly population.
Material and methods
We interviewed 212 community dwelling elderly aged 60 or older (mean age:70.6 SD≥7.16). The validation (assessment of face validity, content validity was carried out in accordance with the literature. The Tilburg Frailty Indicator (TFI) consists of two different parts. One part addresses the potential determinants of frailty and the other specifically addresses the components of frailty, covering its physical, psychological and social domains. Scale reliability was estimated using two methods: Cronbach’s alpha, measuring the scale’s internal consistency, and the test-retest method, determining the scale’s absolute stability. To assess test-retest reliability, the same group was re-interviewed by the same observer within 10-14 days of the first interview
Results
The test-retest reliability showed a high level of agreement for all items of the instrument, with values ranging from 96 to 100%. The Cronbach’s Alpha internal consistency was 0.72.
Conclusion
The Polish version of the TFI proved to be a valid and reliable tool for assessment of FS for the Polish population.

Keywords frailty, questionnairies, validity, aging

Full text

1
Introduction
The Frailty Syndrome (FS) is one of the key health problems
in geriatrics and serves as an index of advanced biological
age. A consequence of frailty is adverse prognosis, such as
functional dependence, falls, recurrent hospitalization and death
(1).
A consistent and commonly accepted FS definition has
not yet been formulated. Thus, there is no consensus on FS’s
diagnostic criteria. One of the first and still frequently used
definitions of FS was proposed in 2001 by Fried et al (1). It
was developed on the basis of a randomized clinical research
trial ‘The Cardiovascular Health Study (CHS)’ performed in
the USA between 1989-1993 on a group of 5,317 respondents
aged 65 years or over (1). The authors identified the Frailty
Phenotype, which incorporates such elements as body
build, nutritional status, and psychomotor status. Symptoms
suggesting FS were weight loss, sarcopenia, nutritional
status, the lowering of physical activity, and the limitation of
physical abilities (1). The latest definitions of FS are based on a
multidimensional concept in which FS is a transitional state in a
dynamic process, dependent on various physical, psychological
and social factors, which interact and disturb the physiological
balance (2-4). A standardized definition of frailty could target
health and social welfare for elderly people by enabling early
detection and therefore reduce both adverse outcomes and the
costs of care. It is of great importance to prevent or delay the
onset of frailty, as well as to affect interventions that target
the pre-frail elderly or those at high risk of becoming frail.
This approach could also improve the quality of life of elderly
people (5).
In the last decade, studies on frailty have become
increasingly frequent in the literature on aging, and also the
number of available questionnaires regarding frailty has
increased over the years. Therefore, the choice of which
questionnaire to use is becoming more difficult (6-16). For
several years, the literature has described new instruments for
FS assessment, based on its multidimensional definition. We
chose the Tilburg Frailty Indicator (TFI), a questionnaire which
has been relatively recently described by Gobbens et al (13)
because it is based on the multidimensional concept of frailty.
Furthermore, a recent systematic review concluded that the
TFI is a potentially relevant tool for screening for frailty in a
primary care setting (17). We selected the TFI and submitted
VALIDITY AND RELIABILITY OF THE POLISH VERSION OF THE TILBURG
FRAILTY INDICATOR (TFI)
I. UCHMANOWICZ1, B. JANKOWSKA-POLAŃSKA1, B. UCHMANOWICZ2,
K. KOWALCZUK3, R.J.J. GOBBENS4,5
1. Department of Clinical Nursing, Wrocław Medical University, Wrocław, Poland; 2. Primary Care Practice, Wrocław, Poland; 3. Department of Integrated Medical Care, Medical
University of Białystok, Białystok, Poland; 4. Faculty of Health, Sports and Social Work, Inholland University of Applied Sciences, Amsterdam, the Netherlands; 5. Zonnehuisgroep
Amstelland, Amstelveen, the Netherlands. Corresponding author: Izabella Uchmanowicz, Department of Clinical Nursing , Wrocław Medical University, K. Bartla 5, 51-618 Wroclaw,
Poland. Tel.: +48 71 784 1824; Fax: +48 71 345 9324. Email: izabella.uchmanowicz@am.wroc.pl
.
Abstract: Background: In the last decade, studies on frailty have become increasingly frequent in the literature
on aging, and also the number of available questionnaires regarding frailty has increased over the years.
Therefore, the choice of which questionnaire to use is becoming more difficult. Objective: The aim of this
study was to assess the psychometric properties of the Polish version of the Tilburg Frailty Indicator (TFI),
an instrument that identifies frailty in the elderly population. Design: Setting, and Participants. The study
was carried out in a community-based setting in Wrocław, Poland. Nurses and doctors (general practitioners)
administered the TFI in primary care facilities. Participants included a sample of 212 community dwelling elderly
aged 60 or older (mean age:70.6 SD≥7.16). Measurements: The validation (assessment of face validity, content
validity) was carried out in accordance with the literature. The Tilburg Frailty Indicator (TFI) consists of two
different parts. One part addresses the potential determinants of frailty and the other specifically addresses the
components of frailty, covering its physical, psychological and social domains. Scale reliability was estimated
using two methods: Cronbach’s alpha, measuring the scale’s internal consistency, and the test-retest method,
determining the scale’s absolute stability. To assess test-retest reliability, the same group was re-interviewed
by the same observer within 10-14 days of the first interview. Results: The test-retest reliability showed a high
level of agreement for all items of the instrument, with values ranging from 96 to 100%. The Cronbach’s Alpha
internal consistency was 0.74. Conclusion: The Polish version of the TFI proved to be a valid and reproducible
tool for assessment of Frailty Syndrome for the Polish population. We would recommend to be used as the
screening tool to assess frailty.
Key words: Frailty, questionnaires, validity, aging.
J Frailty Aging 2015, in press
Published online August 25, 2015, http://dx.doi.org/10.14283/jfa.2015.66
The Journal of Frailty & Aging©
Received March 9, 2015
Accepted for publication May 27, 2015

it to the process of trans-cultural adaptation for use in the
Polish elderly population. This questionnaire was developed
in the Netherlands and consists of two different parts. One part
addresses the potential determinants of frailty and the other
specifically addresses components of frailty, covering the
physical, psychological and social domains of frailty.
The first stages of the trans-cultural adaptation of the TFI
for use with the elderly population in Poland have already been
completed. We observed good comprehension and reasonable
acceptance of the items in the Polish version (18). In this study
we assessed the scale reliability using two methods: Cronbach’s
alpha, measuring the scale’s internal consistency, and the test-
retest method, determining the scale’s absolute stability. The
absolute stability was not tested in the previous study, focusing
solely on the translation and cultural adaptation of the TFI into
Polish (18, 19). Based on this previous study, we decided to
extend our research.
The objective of the study was to evaluate the validity and
reliability of the Polish version of the Tilburg Frailty Indicator.
Methods
Participants
The study was carried out in a community-based setting in
Wrocław, Poland. Data was collected from April 2014 through
to October 2014. Nurses and doctors (general practitioners)
administered the TFI in primary care facilities in Wrocław
during their visits. All participants gave their written informed
consent for participation in the study. Inclusion criteria were
age ≥60 years and written informed consent to participate in
this study. The only exclusion criteria were communication
barriers (e.g., deafness or blindness) or problems with manual
dexterity. This method of studying reliability involves some
difficulties. The values of correlations found depend heavily
on the time interval between the test and retest, as well as on
external factors affecting the variable being measured. The
protocol for the study was approved by the Local Bioethical
Committee of Wrocław Medical University.
Instrument
TFI (in the Appendix the Polish version) consists of two
different parts. One addresses potential determinants of frailty:
the participant’s socio-demographic characteristics (sex,
age, marital status, country of origin, educational level, and
monthly income), lifestyle, multimorbidity, life events and
living environment. The second part addresses the components
of frailty. Part two of the TFI comprises 15 self-reported
questions, divided into three domains. The physical domain
(0–8 points) consists of eight questions related to physical
health, unexplained weight loss, difficulty in walking, balance,
hearing problems, vision problems, strength in hands, and
physical tiredness. The psychological domain (0–4 points)
comprises four items related to cognition, depressive
symptoms, anxiety, and coping. The social domain (0–3
points) comprises three questions related to living alone, social
relations, and social support. Eleven items in part two of the
TFI have two response categories (“yes” and “no”), while the
other items have three (“yes”, “no,” and “sometimes”). “Yes”
or “sometimes” responses are scored 1 point each, while “no”
responses are scored 0. The instrument’s total score may range
from 0 to 15: the higher the score, the higher one’s frailty.
Frailty is diagnosed when the total TFI score is ≥5 (20).
Scale reliability was estimated using two methods. One was
Cronbach’s alpha, measuring the scale’s internal consistency.
The other, determining the scale’s absolute stability, was
the test-retest method, consisting in a comparison between
two interviews with each subject, using the same test. This
comparison included 212 patients who completed the TFI again
10-14 days after the first interview.
Statistical analysis
Statistical analysis was performed using the Statistica 10
package (StatSoft, Tulsa, USA). Significance level of 0.05
was used, i.e. outcomes at p<0.05 were considered statistically
significant. Reliability was assessed using Cronbach’s alpha
reliability coefficient. The discriminative power of items
was measured as item-total correlation. Agreement between
measurements was calculated using the kappa coefficient.
We decided to include at least 200 patients in our analysis
as, according to the literature, the minimum sample size should
be at least five times larger than the number of variables being
analyzed (the number of TFI items is 15, so the minimum
sample size should be 75) (22).
Results
The assessment of the validity and reliability of the TFI
included 212 persons. Most subjects (70.1%) were men. The
mean age was 70.6 (SD=7.16), while the range was 60-90
years. Based on the Polish version of the TFI, the prevalence of
frailty was 44.1%. Table 1 shows descriptive statistics for the
Tilburg Frailty Indicator (TFI) scores in the first interview.
The participants most often replied “Yes” to the following
questions: “Have you felt nervous or anxious during the last
month?” (88%); “Do you sometimes miss having people
around you?” (79%); “Do you experience problems in your
daily life due to physical tiredness?” (74%). The patients most
often replied “No” to the following: “Have you lost a lot of
weight recently without wishing to do so?” (18%); “Do you
have problems with your memory?” (19%).
Table 1 shows descriptive statistics for the Tilburg Frailty
Indicator (TFI) scores in the second interview. The participants
most often replied “Yes” to the following questions: “Have
you felt nervous or anxious during the last month?” (89%);
“Do you sometimes miss having people around you?” (80%);
“Do you experience problems in your daily life due to physical
tiredness?” (74%). The participants most often replied “No” to
the following: “Have you lost a lot of weight recently without
VALIDITY AND RELIABILITY OF THE POLISH VERSION OF THE TILBURG FRAILTY INDICATOR (TFI)
The Journal of Frailty & Aging©
2

wishing to do so?” (15%); “Do you have problems with your
memory?” (20%).
Next, the discriminative power of the TFI was measured
and reported in Table 2. In particular, the discriminative power
coefficients for each item, and the reliability of the whole scale
(estimated using Cronbach’s alpha) with the specific item
eliminated are here reported. The overall reliability for the
scale was α=0.74. This means that the scale is reliable.
Looking at the specific domains, the reliabilities of the
physical, psychological, and social components were α=0.72,
α=0.37, and α=0.59, respectively. This means that only
physical scale might be considered as reliable.
The test-retest reliability of the TFI was determined using
the kappa coefficient. For each of the analyzed questions, the
kappa coefficient indicated very good reliability, with perfect
agreement in one case (Table 1).
Discussion
This study was conducted to continue the process of
transcultural adaptation of the original TFI to the Polish
population (18). Previous research suggests that the TFI is a
valid and reliable instrument for measuring frailty. The TFI is
also efficient: completion of the TFI takes less than 15 minutes
THE JOURNAL OF FRAILTY & AGING
The Journal of Frailty & Aging©
3
Table 1
Descriptive statistics for the TFI variables in the rst and second interview, test-retest reliability
TFI VARIABLES Interview Test-retest reliability
M1st
M2nd
Me1st
Me2nd
SD1st
SD2nd
Min1st
Min2nd
Max1st
Max2nd
Percentage
agreement
Kappa
PHYSICAL COMPONENTS 3.61 4 2.55 0 8
3.57 4 2.20 0 8
1. Do you feel physically healthy? 0.52 1 0.50 0 1 97.6 0.953
0.52 1 0.50 0 1
2. Have you lost a lot of weight recently without wishing to
do so?
0.18
0.15
0
0
0.70
0.36
0
0
1
1
98.6 0.962
3. Do you experience problems in your daily life due to
difculty in walking?
0.49
0.45
0
0
0.77
0.50
0
0
1
1
99.1 0.990
4. Do you experience problems in your daily life due to dif-
culty maintaining your balance?
0.35
0.36
0
0
0.48
0.48
0
0
1
1
99.1 0.979
5. Do you experience problems in your daily life due to poor
hearing?
0.35
0.36
0
0
0.48
0.48
0
0
1
1
99.1 0.979
6. Do you experience problems in your daily life due to poor
vision?
0.64
0.64
1
1
0.48
0.48
0
0
1
1
98.6 0.969
7. Do you experience problems in your daily life due to lack
of strength in your hands?
0.33
0.34
0
0
0.47
0.47
0
0
1
1
97.6 0.947
8. Do you experience problems in your daily life due to
physical tiredness?
0.74
0.74
1
1
0.44
0.44
0
0
1
1
97.6 0.939
PSYCHOLOGICAL COMPONENTS 2.05 2 0.98 0 4
2.11 2 0.98 0 4
9. Do you have problems with your memory? 0.19 0 0.39 0 1 97.6 0.970
0.20 0 0.40 0 1
10. Have you felt down during the last month? 0.67 1 0.47 0 1 99.5 0.946
0.69 1 0.46 0 1
11. Have you felt nervous or anxious during the last month? 0.88 1 0.32 0 1 99.5 0.977
0.89 1 0.32 0 1
12. Are you able to cope with problems well? 0.31 0 0.46 0 1 96.2 0.913
0.33 0 0.47 0 1
SOCIAL COMPONENTS 1.42 1 0.84 0 3
1.44 1 0.83 0 3
13. Do you live alone? 0.34 0 0.47 0 1 99.1 0.979
0.35 0 0.48 0 1
14. Do you sometimes miss having people around you? 0.79 1 0.41 0 1 99.1 0.971
0.80 1 0.40 0 1
15. Do you receive enough support from other people? 0.29 0 0.46 0 1 100 1.000
0.29 0 0.46 0 1
M - mean, Me - median, SD - standard deviation, Min - the smallest value, Max - the largest value; 1st First Interview, 2nd Second Interview

and does not require face-to-face contact (13). The TFI proved
to be a valid measurement tool in our study sample, consisting
of 212 community-dwelling elderly. The internal consistency
of the adapted scale was determined by means of Cronbach’s
alpha. On the basis of our analysis, all domains of the TFI
can be considered valid and reliable. For all the items on the
scale, Cronbach’s alpha is 0.74, which indicates the high
internal consistency of the scale. This value is similar to that
documented in the case of the original Dutch version of the
TFI (0.73) (20) and its Brazilian adaptation (0.78) (23). Some
studies suggest that the internal consistency of items should be
classified as follows: values ≥0.9 as excellent, ≥0.8 as good,
≥0.7 as acceptable, ≥0.6 as questionable, ≥0.5 as poor, and
<0.5 as unacceptable. However, there is actually no lower limit
to the coefficient (24). In the present study, we report on the
psychometric properties (test–retest reliability, and internal
consistency) of the Polish version. The reliability of the Polish
version is good, evidenced by strong test–retest reliability,
fair-to-high simple- and chance-corrected item agreement, and
adequate internal consistency of the TFI total score. Gobbens
et al (20) found similar two-week reliability and test-retest
reliabilities of 0.67 or higher. The time interval was similar in
our study (10-14 days). The internal consistency reliability of
the psychological and the social frailty domains was low, which
was also observed for the original TFI. Gobbens et al (20)
found 0.63 and 0.34 for the psychological and social domain,
respectively, values which correspond to our values of 0.59
and 0.37. Gobbens et al (20) did not consider this a problem
for the original TFI, because they selected the components of
frailty to cover the most important elements and its domains in
as few questions as possible.
According to the literature, up to 40% of older people can
be considered frail (22). This statement would be supported
by the results presented here, since as many as 44.1% of our
participants were identified as frail on the basis of TFI scores
≥5. Furthermore, the proportion of frail individuals documented
VALIDITY AND RELIABILITY OF THE POLISH VERSION OF THE TILBURG FRAILTY INDICATOR (TFI)
The Journal of Frailty & Aging©
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Table 2
The Tilburg Frailty Indicator (TFI) reliability analysis results and physical, psychological and social components’ reliability
analysis results for the whole scale, and for the single domains
TFI VARIABLES Item-total
correlation –
discriminative
power whole scale
Cronbach’s alpha
with the item
eliminated whole
scale
Item-total
correlation –
discriminative
power for the
single domains of
the TFI
Cronbach’s alpha
with the item
eliminated
for the single
domains of the TFI
PHYSICAL COMPONENTS
1. Do you feel physically healthy? 0.513 0.714 0.475 0.681
2. Have you lost a lot of weight recently without wishing to do so? 0.254 0.743 0.300 0.719
3. Do you experience problems in your daily life due to difculty in
walking?
0.498 0.713 0.548 0.661
4. Do you experience problems in your daily life due to difculty
maintaining your balance?
0.546 0.711 0.497 0.677
5. Do you experience problems in your daily life due to poor
hearing?
0.367 0.729 0.380 0.700
6. Do you experience problems in your daily life due to poor vision? 0.296 0.737 0.296 0.716
7. Do you experience problems in your daily life due to lack of
strength in your hands?
0.402 0.726 0.372 0.702
8. Do you experience problems in your daily life due to physical
tiredness?
0.506 0.717 0.459 0.687
PSYCHOLOGICAL COMPONENTS
9. Do you have problems with your memory? 0.440 0.724 0.264 0.237
10. Have you felt down during the last month? 0.225 0.743 0.255 0.236
11. Have you felt nervous or anxious during the last month? 0.159 0.746 0.174 0.336
12. Are you able to cope with problems well? 0.371 0.729 0.124 0.403
SOCIAL COMPONENTS
13. Do you live alone? 0.118 0.754 0.223 0.718
14. Do you sometimes miss having people around you? 0.235 0.741 0.210 0.692
15. Do you receive enough support from other people? 0.263 0.739 0.321 0.710

in the aforementioned Brazilian validation study of the TFI was
well above 30% (23).
Having completed the stages in this study, we may conclude
that the Polish version of the TFI proved to be suitable for use
in the elderly Polish population.
The main limitation of our study consists in the likely non-
representativeness of our sample for the general population of
older people. In fact, only the subjects who had been referred to
a general practitioner were here examined.
In conclusion, the Polish version of the TFI proved to be
a valid and reproducible tool for assessment of FS for the
Polish population. The use of this screening tool for frailty is
recommended.
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VALIDITY AND RELIABILITY OF THE POLISH VERSION OF THE TILBURG FRAILTY INDICATOR (TFI)
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Appendix
Polish version of the TFI
Wskaźnik Słabowitości Tilburg (TFI)*
Gobbens RJJ, van Assen MALM, Luijkx KG, Wijnen-Sponselee MTh, Schols JMGA. Wskaźnik Słabowitości Tilburg: właściwości psychometryczne. J Am Med Dir
Assoc 2010; 11(5):344-355.
Część A Determinanty słabowitości
1. Jakiej jesteś płci? □ mężczyzna
□ kobieta
2. Ile masz lat? ............................ lata/lat
3. Jaki jest twój stan cywilny? □ żonaty/mężatka/mieszkam z
partnerem
□ nieżonaty/niezamężna
□ w separacji/rozwiedziony/a
□ wdowa/wdowiec
4. W jakim kraju się urodziłeś? □ Polska
□ Inny, (podaj kraj) ................
5. Jakie posiadasz wykształcenie? □ żadne lub podstawowe
□ średnie
□wyższe zawodowe lub wyższe
6. Do której kategorii zalicza się miesięczny
dochód netto w twoim gospodarstwie domowym?
□ 600 PLN lub mniej
□ 601 - 900 PLN
□ 901 - 1200 PLN
□ 1201 - 1500 PLN
□ 1501 - 1800 PLN
□ 1801 - 2100 PLN
□ 2101 PLN lub więcej
7. Ogólnie rzecz biorąc, jak oceniasz swój styl życia pod kątem zdrowia? □ zdrowy
□ ani zdrowy, ani niezdrowy
□ niezdrowy
8. Czy masz dwie lub więcej chorób i/lub chroniczne zaburzenia? □ tak □ nie
9. Czy doświadczyłeś jednego lub więcej z następujących zdarzeń w ciągu ostatniego roku?
- śmierć ukochanej osoby □ tak □ nie
- ciężka choroba u siebie □ tak □ nie
- ciężka choroba u ukochanej osoby □ tak □ nie
- rozwód lub koniec ważnego związku □ tak □ nie
- wypadek samochodowy □ tak □ nie
- przestępstwo □ tak □ nie
10. Czy jesteś zadowolony ze swego środowiska domowego? □ tak □ nie
Część B Składniki słabowitości
B1 Składniki zyczne
11. Czy czujesz się zdrowy zycznie? □ tak □ nie
12. Czy ostatnio straciłeś sporo na wadze, mimo że nie chciałeś? („sporo” to 6 kg lub więcej na przestrzeni ostatnich sześ-
ciu miesięcy lub 3 kg w przeciągu ostatniego miesiąca)
□ tak □ nie
Czy na co dzień doświadczasz trudności z powodu:
13. ............ trudności w chodzeniu? □ tak □ nie
14. .......... trudności w utrzymaniu równowagi? □ tak □ nie
15. ......... słabego słuchu? □ tak □ nie
16. ......... słabego wzroku? □ tak □ nie
17. .......... braku siły w dłoniach? □ tak □ nie
18. ........... zycznego zmęczenia? □ tak □ nie
B2 Składniki psychologiczne
19. Czy masz problemy z pamięcią? □ tak □ czasami □ nie
20. Czy zdarzył Ci się spadek nastroju na przestrzeni ostatniego miesiąca? □ tak □ czasami □ nie
21. Czy odczuwałeś zdenerwowanie lub podniecenie na przestrzeni ostatniego miesiąca? □ tak □ czasami □ nie
22. Czy umiesz sobie dobrze radzić z problemami? □ tak □ nie
B3 Składniki społeczne
23. Czy mieszkasz sam? □ tak □ nie
24. Czy zdarza Ci się tęsknić za towarzystwem innych osób? □ tak □ czasami □ nie
25. Czy otrzymujesz wystarczająco dużo wsparcia od innych? □ tak □ nie
* Wskaźnik TFI został przetłumaczony na angielski za pomocą tłumaczenia wstecznego.