Psychometric adequacy of the Persian adapted version of the Tilburg Frailty Indicator (P- TFI)

doi:10.21203/rs.3.rs-3235854/v1

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Research Article

Psychometric adequacy of the Persian adapted version of the Tilburg Frailty Indicator (P- TFI)

https://doi.org/10.21203/rs.3.rs-3235854/v1

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published 21 Jul, 2024

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Background:

Frailty has been identified as the primary goal of the preventing the various s aging consequences in many studies. Considering frailty help us to plan and train properly. valid and reliable tools are needed. The current study aimed to assess validity and reliability of the Persian adapted version of the Tilburg frailty indicator in Iran.

Method:

The current study is cross sectional study included three phases: at first phase, the indicator translated to Persian, at the next step, face and content validity was assessed. During the third phase, the P-TFI was sent out for completion to elderlies, who helped assess reliability and construct validity. For construct validity, convergent and divergent validity were used. It was expected that the TFI domain scores would show the highest correlations with their related measures of frailty (convergent construct validity) and the lowest correlations with measures of the other domains (divergent construct validity). Overall, 400 elderlies entered the study as the study population from six health care centers.

Results

The mean age of the participants was 69.05±7.28 (ranged from 60 to 93) years old. The majority of the participants were female (56.8). More than half of the participants had spouse. The majority had less than twelve years of education (81.5%), and most participants had a modest level of income. an overall of 168 (42%) older people lived with their spouse and child. The mean total score of TFI was 8.26±1.80, and 171 participants (42.75%) were classified frail in terms of the original cut-point of the scale (i.e., the total score ≥5): with the, and considering 6 as the threshold limit for TFI (i.e., The total score ≥6), 89 participants (22.25) were classified as frail. The scores for KR-21 range from 0 to 1, where 0 is no reliability and 1 is perfect reliability. The test-retest reliability for the 14-day interval was 0.88 for the total scale, 0.80 for physical domain, 0.65 for psychological domain and 0.81 for social domain. Mean score of frailty and its dimensions varied from 4.35±1.78, 1.81±1.33,1.69±0.73.0.86±061 for total frailty, physical, psychological and social respectively. The total score of the TFI significantly correlated with each alternate measure as expected. The convergent validity of the TFI was proved by the Cohen’s kappa coefficient between each item of the TFI and corresponding alternate tools. All of the kappa values ranging from.535 to 0.967 were statistically significant.

Tilburg frailty indicator

Validity

Reliability

Iran

Ageing is global phenomenon [1]. In the year 2031, 20 to 25% of the population of Iran will be aged [2]. Aging reduces the physiological capability and functional reserve of various organs of the body. acute reduction of the storage capacity, frailty occurs [3]. Frailty is one of the main issues faced by the elderly people [4]. Frailty refers to a state of susceptibility to various side effects such as falling, inability, hospitalization and poor quality of life [5–8]. It is estimated about 10% of the people equal and above 60 years old are frail [9]. Frailty associated with decreased functional capacity and increased mortality rate [10]. Frailty has been identified as the primary goal of the preventing the various s aging consequences in many studies [11].

Considering frailty help us to plan and train properly. valid and reliable tools are needed to achieves this goal. Various tools have been designed related to frailty assessment, e.g., frailty index have been designed for frailty assessment in the elderlies.

Frailty index designed based on a number of health-related defects such as symptom, sign, diseases, infirmity, or laboratory measures [12] and it’s filling out takes a lot of time.

Groningen Frailty Indicator (GFI), focus on disability [13] While frailty does not mean disability [14]. Fried 'phenotype' frailty inventory fills out with face-to-face interviews and its tools which used by specialist for assessing of physical function [15].

Whereas the Tilburg frailly index (TFI) is known as a standard self-report questionnaire, that focusses on predictors of life expectancy, illness, and adverse outcomes such as disability, facilities health care, and death. This index compromised two sections. The first one consisted 10 items and pointed to frailty predictors and other one emphasizes on the disability elements, and accompany by three aspects and in ability is the result of frailty [16]. TFI designed by Gobbens et al. in 2010 by considering the WHO health definition [14]. The psychometric properties of the TFI were assessed among older adults in various countries such as Poland [17] Brazil [18], Italy [19], Portugal [20] and Danish [21]. But the desirable features of the tool have not yet been evaluated in terms of validity and reliability in Iran. The current study aimed to assess validity and reliability of the Persian adapted version of the Tilburg frailty indicator in Iran

The current study is cross sectional study included three phases:

Phase 1

Translation

The first version of the TFI was translated into Persian after being written permission from original developer similar to modified Brislin’s translation model [22]. according to the model, at first, two expert English-Persian translator apart from each other translated TFI from English into Persian. Second, another translator prepared the last Persian translation by combine the two main Persian translations. Afterward, two other English native translators translate the final Persian translation into English.

Finally, two version of the English back-translations and original version were compared to and the differences were determined and some modification was applied in some instances.

Phase 2

Content and face validity

Ten specialists (Gerontology and public health, health promotion) were assessed the index qualitatively and face validity was assessed using the views of the 20 Iranian’s elderly.

Phase 3

During the third phase, the P-TFI was sent out for completion to elderlies, who helped assess reliability and construct validity.

Reliability

Test-retest and Cohen Kappa coefficient were used for assessing reliability.15 subjects considered as the minimum sample size for test-retest reliability [23] fill out the questionnaire two times (2 weeks’ interval) for test –re test reliability and Cohen Kappa coefficient was used for assessing internal consistency and 0.60 considered as the acceptable level [24]

Construct Validity

For construct validity, convergent and divergent validity were used. It was expected that the TFI domain scores would show the highest correlations with their related measures of frailty (convergent construct validity) and the lowest correlations with measures of the other domains (divergent construct validity).

Predictive validity:

Furthermore, Activity Daily Living (ADL) and Instrumental activities of daily living (IADL) were used to assess predictive validity. In addition, the correlations between the dimensions of TFI and related dimensions in the quality-of-life (QoL) questionnaire was assessed.

Participations

Overall, 400 elderlies entered the study as the study population from six health care centers. According to Comrey & Lee indication, 200 was adequate for sample size [25]. For selecting the sample, a list of the Karaj health centers provided and six centers were picked up at random (simple random) in the next stage; then the convenience sampling method was used in each center to select the subjects who met inclusion criteria.

Data collection

Elderly people who have received free health services from the health care centers and aged above 60 years completed the questionnaires. The questionnaires filled out by face-to-face interview. Four interviewers conducted the interview due to a standardized procedure during 2 months. Informed written consent was obtained from all participants prior interview and the study followed The Declaration of Helsinki.

Measures:

TFI- Part B

The TFI included of fifteen yes/no questions about physical, psychological, and social domains of frailty included each domain, 8 items, 4 items and 3 items respectively. The original developer of the original FTI suggested, if the total score is 5 or above, the subjects categorize as frail.

Other Measures of Frailty

Various tools and physical indicator were used to assess the components of frailty[Table1].

Table 1

Alternates measures of the TFI with continuous and dichotomous variable. Items of the TFI
Questions	Alternative measures Continuous variables	Categorical variables
1. Do you feel physically healthy?	In general, how would you rate your health? (Excellent, very good, good, fair or poor)	Excellent, very good or good = 0; fair = 1
2. Have you missing a lot of weight recently without wishing to do so?	Participants met our criteria for shrinking if they had a BMI of 18.5 kg/m2 or less, or if they reported that they had lost 5 or more kilograms in the previous year.	≥ 5% indicating shrinking (Fried et al., 2001)
3. Do you experience any difficulty in your daily life due to problematic walking?	Walking speed was measured by calculating the average time required to complete a 4-meter walk. Participants were asked to get up from a chair with a handle, walk 4 meters, then turn back and walk back to the chair and sit on it.. Which was measured with a stopwatch (chen, et al 2015)	> 5 presented as difficulty in walking
4. Do you experience any difficulty in your daily life due to existence problem in maintaining your balance?	TUG test The TUG test measures the time the respondent takes to rise from an armchair, walk three meters, and return to the chair.	< 10s indicated 0 and > 10 indicated difficulty in balance
5. Do you experience any difficulty in your daily life due to poor hearing?	Making telephone calls (independent, need help or unheard)	'Need help' or ‘unheard' indicating hearing impairment
6. Do you experience problems in your daily life due to poor vision?	Can you see the words on this questionnaire clearly by the distance (about 20 cm)? (Extremely, quite a bit, somewhat, a little bit or not at all)	'Somewhat' to ‘not at all' indicating vision impairment
7. Do you experience any difficulties in your daily life due to lack of strength in your hands?	A modified sphygmomanometer was used to measure hand muscle strength. For this purpose, the subjects were asked to sit completely comfortably in a chair with a handle and place their hands in a comfortable position on the chair holder (at a 90-degree angle) and by holding the corrected sphygmomanometer, the strength of their hands was measured	> 135–145 mmHg considered as difficulty in hand strength
8. Do you experience any difficulties related to your physical tiredness?	How tired have you been over the past month: Full time: 1, most of the time: 2, sometimes: 3, little time: 4, never: 5 If the answer was all the time or most of the time, the score was one, and if the score was sometimes, little or never, the score was zero.	'All of the time' to ‘a little of the time' indicating problems in your daily life due to physical tiredness
9. Do you have any difficulties with your retention?	The 20- items Mini Mental State Examination (MMSE)	Cognitive impairment determined by a score less than 21[ 57Cano et al, 2012]
10. Have you depressed during the last month?	The 15-item Geriatric Depression Scale (GDS-15)	≥ 4 indicating felling down
11. Have you felt furious or worry during the last month?	During the past 4 weeks, have you furious the amount of time you spent on work or other activities as a result of any emotional difficulties (such as feeling depressed or anxious) (all of the time, most of the time, some of the time, a little of the time, or none of the time)	'All of the time' to ‘a little of the time' Presented dysfunctional emotion role
12. Are you able to cope with difficulties well?	I am able to do, what I want (strongly agree, agree, neutral, disagree or strongly disagree)	'Neutral' to ‘strongly disagree' indicating unable to do at one's will
13. lonely living?	who do you live with? (Living with family or living alone)	Living alone indicating positive
14. Do you sometimes miss having people around you?	The Adaptability, Partnership, Growth, Affection and Resolve (APGAR) scale	< 7 was considered as having family dysfunction
15. Do you receive adequate support from other people?	The Social Support Rating Scale (SSRS) (Xiao, 1994)	Less than the 25 were classified as having low social support

Physical frailty which are the Persian version Physical activity for elderly (P-PASE) [26], the Body Mass Index (BMI), the Gate Speed [27] TUG test[ 28] ,one item to poor hearing, one item to determine poor vision and one item to assess poor hearing, a hand grip strength test using a changed sphygmomanometer [29],one item to assess tiredness, Cognitive impairment evaluate using Mini Mental State Exam (MMSE)[ 30], The 15-item Geriatric Depression Scale (GDS-15) for assessing feeling down[31], 1 question to assess nervous or anxious feeling, 1 question to assess to cope with problems ,1 question to assess living arrangement, family disfunction assessed by The adaptability, partnership, Growth, Affection and resolve (APGAR)[32]and, Social support assessed by the Social Support Rating Scale (SSRS)[ 33].

The PASE compromised of 12 items related to the activities performed during past week. About each item, Weight, frequency and duration were assessed. The total score of the scale obtained by multiplying the amount of time spent in each activity (h/day) or activity participation (yes/no) by the weights of the items and then, summing the results [34]

The PASE translated and assessed related to validity and reliability in Iran by Keikavoosi & Salehi [26]. The Walking speed was assessed by computed the mean time required to complete a walking until 4-meters. Participants were asked to get up from a chair with a handle, walk 4 meters, then go back and walk to the chair and sit on it. that was measured with a Mobile pedometer [27] The time up and go (TUG) test measures the time the respondent takes to rise from an morris chair, walk three meters, and return to the chair [28], Poor hearing and vision difficulties were determined by asking participants to making calls by telephone, and by questionnaire reading respectively. Handgrip strength was measured by a changed sphygmomanometer which was used to assess strength of hand muscle. For this purpose, attainment, the subjects were asked to sit completely comfortably in a chair with a batch and place their hands in a comfortable position on the chair catch (at a 90-degree angle) and by keeping the corrected sphygmomanometer, the strength of their hands was assessed

boring assessed by asking the subjects regarding tiredness during the last 4 weeks, the question scored by Likert rating scale from all the time to never, Mini mental status examination (MMSE) [35] included 17 items, and it a widely used to test cognitive function in the elderly; by using MMSE orientation, attention, computation and memory, language and visual-spatial skills were evaluated. this questionnaire assessed related to psychometric properties among Iranian's older adults and reached optimal validation [37]. Geriatric Depression Scale (GDS) is brief scale related to the elderly depression. GDS, includes 15 yes/no and 15 items (10 items shows the depression existence among participants. And other items (no.1, 5, 7,11,13) indicated depression in negatively responses. by summing the scores items, 0–4 reflected normal, considering age, education, and complaints; 5–8 reflect mild depression; 9–11 reflect moderate depression; and 12–15 reflect severe depression [38]. Scale validation assessed by Malakouti et al in Iran [39]. Activity Daily living (ADL) included the people's usual daily activities. It was considering as marker for assessing functional activity particularly related to individuals with posttraumatic difficulties, feeble persons and older adults. ADL compromised of feeding, bowl and bladder control, dressing and undressing, chair and bed transferring, bathing and toileting [39]. ADL validated in Iran [40]. Instrumental activities of daily living (IADL) indicate participants’ difficulties with (I) ADL, it was compromised seven items such as use of telephone, shopping, food preparation, doing housework, ability to handle finances, responsibility for self-medication, and transporting out. IADLs included the activities performance whose is necessary for autonomous living. Dependency, needing partial help, and independency scored as 0, 1, and 2, respectively; the higher score shows greater dependency. IADL was validated in the Persian culture [ 40]

APGAR stands for adaptability, partnership, Growth, Affection and resolve (APGAR) and compromised 5 items related to five family function satisfaction (adaptation, partnership, growth, affection and resolve). The response might be 0, 1, 2 for each item and overall have a range between 0 and 10 resulting from sum of the scores of each item [41]. Family APGAR validated in Iranian older adults by Karimi et al, 2022[42]

Social Support Rating Scale (SSRS) [ 33] included 10 items and three subscales. mental social support (4 cases), objective social support (3 cases) and supportive behavior (3 cases). 4-point Likert score was used to score each item. The total SSRS score is the computation of the three subscales items. A higher score represents more social support.

The WHOQOL included four domains (psychological health: 6 items, Physical health: seven items, social health: three items; environmental health: eight items) with 26 items and a total Qol items, in addition one item pertains to general health. This self-administered questionnaire is cross-cultural instrument. Five-points Likert scale was used to score the items. [43, 44]

Data analysis

The Cronbach’s alpha coefficient was used to assess the internal consistency of the items of the TFI and its domains, which is evaluated as acceptable if it is at least 0.70. Test-retest reliability was assessed by computing intra-class correlated coefficients (ICC), and was assessed by using the Caligari Jacques categories [45] (weak, 0.00–0.30; moderate, 0.30–0.60; very well, 0.60–0.90, excellent, ≥ 0.90). The Cohen’s kappa coefficients between each item of the TFI and it’s related to further measure, as well as Pearson correlation coefficients between three domains of the TFI and others frailty measures were used to assess the construct validity of the TFI. The convergent validity was proved by statistically significant Kappa coefficients. The agreement between each item of the TFI and its related measure (dichotomized variables) was evaluated using kappa coefficients (46) [< 0, poor; 0–0.20, Low; 0.21–0.40, relatively low; 0.41–0.60, to a moderate extent; 0.61–0.80, considerable; 0.81–1.00 well].

The convergent validity was also evaluated by statistically significant Pearson correlation coefficients. The divergent validity was expected that each alternate measure would have higher correlations with the same domain of the TFI, and lower correlations with other domains of the TFI.

ADL disability, IADL disability, were used as outcomes to examine predictive validity of the total TFI and TFI physical domain, depression as an outcome to examine concurrent validity of the total TFI and TFI psychological domain, and low social support as an outcome to examine concurrent validity of the total TFI and TFI social domain, respectively. IBM SPSS Statistics 19.0 was recruited to assess for analysis the study data. One-tailed tests were used, and a P < 0.05 was considered statistically significant.

Participant characteristics

The mean age of the participants was 69.05 ± 7.28 (ranged from 60 to 93) years old. The majority of the participants were female (56.8%). Other traits are presented in Table 2.

Table 2

The Participant's characteristics(n = 400)
Characteristic	N (%)	M ± SD
Age (M ± SD)		69.05 ± 7.28
60–74	313(78.25)	65.95 ± 4.17
75–84	66(16.5)	78.06 ± 2.84
> 85	22(5.5)	86.77 ± 2.28
Sex
Male	173(43.3)
Female	227(56.8)
Education
< 12	324(81.5)
12	50(12.5)
> 12	24(6)
BMI
< 19	9(2.25)
19-24.9	149(37.25)
25-29.9	169(42.25)
> 30	73(18.25)
Marital Status
Married	286(71.5)
Unmarried (Single, Divorce & widow)	114(28.5)
Co-Living
Alone	62(15.5)
with spouse and child	168(42)
With spouse without child	117(29.3)
With child	53(13.3)
Economic Status
Appropriate	149(37.25)
Intermediate	177(44.25)
Inappropriate	74(18.5)

More than half of the participants had spouse. The majority had less than twelve years of education (81.5%), and most participants had a modest level of income. an overall of 168 (42%) older people lived with their spouse and child. The mean total score of TFI was 8.26 ± 1.80, and 171 participants (42.75%) were classified frail in terms of the original cut-point of the scale (i.e., the total score ≥ 5): with the, and considering 6 as the threshold limit for TFI (i.e., The total score ≥ 6), 89 participants (22.25) were classified as frail.

Reliability

The Kuder-Richardson 21 coefficient of internal consistency reliability of the TFI was 0.81 for the total scale, 0.87 for the physical domain, 0.71 for the psychological domain, and 0.88 for the social domain, respectively. The scores for KR-21 range from 0 to 1, where 0 is no reliability and 1 is perfect reliability. The closer the score is to 1, the more reliable the test. In general, a score of above 0.5 is usually considered acceptable [47]

The test-retest reliability for the 14-day interval was 0.88 for the total scale, 0.80 for physical domain, 0.65 for psychological domain and 0.81 for social domain.

Mean score of frailty and its dimensions varied from 4.35 ± 1.78, 1.81 ± 1.33,1.69 ± 0.73.0.86 ± 061 for total frailty, physical, psychological and social respectively[Table3].

Table 3

Mean Score of frailty and its dimensions (n = 400).
Frailty	Mean	SD	Median	Min	Max
Physical	1.81	1.33	2	0	10
Psychological	1.69	0.73	2.00	0	3
Social	0.86	0.61	1	0	1
Total	4.35	1.78	4	1	12

Construct validity (convergent and divergent validity)

As shown in Table 4, the total score of the TFI significantly correlated with each alternate measure as expected. The convergent validity of the TFI was proved by the Cohen’s kappa coefficient between each item of the TFI and corresponding alternate tools

Table 4

Construct validity (Convergent validity): kappa coefficients between each item of the TFI and corresponding alternative Frailty Measures.
Items of TFI Physical domain	Scale	KAappa	P
Q11.Do you feel physically healthy?	Fair or poor health (SRH)	.658	.000
Q12.Have you lost a lot of weight recently without willing?	Shrinking	.558	.000
Q13.Do you experience problems in your daily life due to difficulty in walking?	Slowness of walking speed	.689	.000
Balance Q14.Do you experience problems in your daily life due to difficulty maintaining your balance?	Balance difficulty (TUGT)	. 521	.000
Q15.Do you experience problems in your daily life due to poor hearing?	Hearing defect (making telephone call)	.567	.000
Q16.Do you experience problems in your daily life due to poor vision?	Vision defect (see the words on questionnaire	. 507	.000
Q17.Do you experience problems in your daily life due to lack of strength in your hands?	Weakness (grip strength)	.515
Q18.Do you experience problems in your daily life due to physical tiredness?	Exhaustion (poor endurance)	.500	.000
Psychological domain Cognition		.. 623	.000
Q19.Do you have problems with your memory?	Cognitive impairment (MMSE)
Mood Q20.Have you felt down during the last month?	Depression (GDS-15)	. 613 .555	.000
Q21.Have you felt nervous or anxious during the last month?	Dysfunctional emotion role (emotional role)	.508	.000
Social domain Living alone	Unable to do at one’s own will (I am able to do, what I want”	.428 .0.06	.000 .000
Q23.Do you live alone?	Living arrangement	.428 .0.06	.000 .000
Social connections		.013	.000
Q24.Do you sometimes miss having people around you?	Family dysfunction (APGAR)	.013	.000
Social support		− .272	.000
Q25.Do you receive adequate support from other people?	Low social support (SSRS)	− .272	.000

All of the kappa values ranging from.535 to 0.967 were statistically significant (Table 4).

Table 4 shows the correlations of the total TFI and its three domains with alternate tools. The physical aspects correlated as expected and significantly with the others physical measures, showing a good convergent validity. Its divergent validity was also well, because its correlations with alternate physical tools were higher than with the other frailty dimensions. additionally, there is a significant and good correlation between it and physical QoL domain. The psychological domain had good convergent validity because of its significant correlations with each alternate measure, but its divergent validity was not good. The social domain showed both good convergent and divergent validity, because the social frailty correlated as expected and significantly with its each alternative measure, and correlated more strongly than did the other two domains. Furthermore, there are significant and weak to moderate correlation between psychological and social frailty and their corresponding QoL domains[Table5]

Table 5

Construct validity (convergent and divergent validity): Pearson correlation coefficients between the scores of TFI domains and self-rated health, PASE, and ADL and IADL, MMSE, GDS, SSC and QoL dimensions.
TFI	TFI Ph		TFI Ps		TFI So
TFI	r	P	r	P	r	P
Physical Domain
ADL	-0. 691	< 0.001	-0.385	< 0.001	-0.268	< 0.001
IADL	-0. 423	< 0.001	-0.235	< 0.001	-0.089	< 0.001
PASE	-0.304	< 0.001	-0.118	0.018	-0.004	0.943
Psychological Domain
MMSE	-0.244	< 0.001	-0.443	< 0.001	0.81	0.719
GDS	0.053	< 0.001	0.300	< 0.001	0.601	< 0.001
Social Domain
Social Support	-0.115	0.022	-0.55	0.272	-0.451	< 0.001
QoL Dimensions
Physical	-0.402	< 0.001	-0.277	< 0.001	-0.251	< 0.001
Psychological	-0.507	< 0.001	-0.363	< 0.001	-0.298	< 0.001
Social	-0.408	< 0.001	-0.307	< 0.001	-0.290	< 0.001
Environment	-0.424	< 0.001	-0.304	< 0.001	-0.307	< 0.001
TFI, Tilburg Frailty Indicator; TFI Ph, Tilburg Frailty Indicator physical domain; TFI Ps, Tilburg Frailty Indicator psychological domain; TFI So, Tilburg Frailty Indicator social domain. QoL: Quality of Life, * One-tailed P value.

TFI is a frailty scale that distinguishes disability and comorbidity; also, it compromised physical, psychological, and social domains. It is a brief-self reported tool and little time consuming to fill out, and short instruction. additionally, Total FTI score calculate easily to identification and intervention toward frail older adult can be improved by use it [48]

The current study designed to translate and evaluate the psychometric properties of the scale among a sample of community-based older people in Iran. Other studies have shown that the TFI is a valid and reliable instrument for assessing frailty [20, 14, 19, 18, 20]. Test–retest reliability for the total frailty score was at acceptable level (r = 0.72). This result far from the previous studies results, which were 0.90 among Dutch, 0.91 among Portuguese, 0.87 among German, and 0.88 among Brazilians, respectively. Test–retest reliability for three domains were also at acceptable level and lower than to the other related findings [14, 17, 18, 20]. It was supposed it might be due to longer interval between two tests in this study. it was 14 days and in the other studies it was 10 days.

Convergent validity of the TFI was confirmed by statistically significant kappa coefficient of each TFI item with their related measures. The majority of the TFI items had good and excellent agreement with related frailty measures, but another study showed fair or moderate agreement with alternative frailty measures validity except for cognitive functions, it was moderate and for living arrangement, it was excellent [49].

The divergent validity showed that there is a significant correlation between each of the TFI domains with the related alternate instrument, which was obtained in the domains of the social and physical good and the psychology domain was very good.

Related to the MMSE (DO you have difficulties with your memory?) correlation to TFI Psychological domain, it was not strong. Other studies also showed cognitive difficulty of elderlies had stronger correlation with physical domain of the physical compared to psychological frailty [14, 18]. According to other studies, Cognitive disorders cause dependence in the elderly. [50, 14]. The current study findings also showed that the GDS-15 had a stronger correlation with the physical domain than with the psychological domain. and also, GDS-15 had a strong correlation with social frailty. This can be showed by the findings in the following study on frailty and physical and mental functions. A study among Taiwanese older people [8] found that physical frail participants were probability to have lower

quality of life scores for two domains of the questionnaire, both the physical and mental domains, but in pre-frail older persons low SF-36 scores observed in only the mental domain. These results propose that psychological problems can lead to low physical functioning and higher isolation. Furthermore, Qi& Li study results presented that worse social frailty accompanied with a significant degree of depression [51]

In the Portuguese community dwelling older people, 6 was chosen as a cut-off for frailty, and 54.8% of the participants were frail [20]. The prevalence of frailty was also higher than that in the current study. Three reasons could be able to explain this phenomenon. at first, it should mention, in the current study the participants' inclusion criteria of age (≥ 60 years) was younger than that in the other foreign studies (≥ 65 years). Second, in cultures similar eastern cultures such as the culture of the studied samples, the elderly often lives in the family and among their children and grandchildren, which brings them more mental health. Third, Elderly Muslims, including Iranians, have a habit of saying "thank God" in any situation even in the.

the worst situations

Some limitations could be highlighted in the current study. First, the cross-sectional nature of this study prevents the investigation of the causal relationship between the frailty and adverse outcomes and cannot assess the predictive validity of the TFI. It is recommended to investigate the causal relationship in the prospective longitudinal studies. c. As the most of the subjects in this study had a low educational level, we used face to face interview for filing out the TFI while the original TFI is a self-administered instrument. This may be time-consuming and affect the accuracy of the results. Overall, it takes little time to fill out questionnaire and good and significant agreement of the questionnaire items with alternate instruments confirms the validity of the instrument in Iranian culture.

In addition, the overestimation caused by the potential overlap between some tool items of the TFI with some alternate tools such as GDS-15 and SSRS should be taken into account in predictive validity of the TFI related to depression and social support.

Overestimation is inevitable because There is evidence that indicates the intertwining of frailty and depression [ 52] furthermore, a previous study showed, older people living alone were in greater risk of the frailty [53]. Finally, we Just conducted the study on the elderly who receive services from urban health centers, and they may be different from other elderly in some aspects, such as socioeconomic status and friendship and support networks That can affect our results.

Groningen Frailty Indicator: GFI; Tilburg frailly index: TFI; Activity Daily Living: ADL; Instrumental activities of daily living: IADL; quality-of-life: QoL; Persian version Physical activity for elderly :P-PASE; Body Mass Index: BMI; TUG test: Timed Up and Go test; Mini Mental State Exam: MMSE; the Social Support Rating Scale: SSRS; for adaptability, partnership, Growth, Affection and resolve: APGAR; WHOQOL: WHO QoL; intra-class correlated coefficients: ICC;

Ethics approval and consent to participate

Ethical Committee of Alborz University of Medical Sciences approved the study (approval number: IR. Abzums.1398.223). All the participants signed the informed written consent forms. All the participations were assured regarding their privacy in this study and informed about volunteer entering in the study and willingness to exclude from the study at any time. All methods in the current study were carried out in accordance with the Declaration of Helsinki.

Consent for publication

Not applicable.

Competing interests

The authors declare that there is not any conflict of interest.

Funding

This study conducted without any funding.

Authors’ contributions

MS: Wrote manuscript and contributed in perform the study

LS: supervised the study; contributed to the study design and conducted the analysis and write the manuscript

Availability of data and materials

The current study datasets and analysis sheets are available and will be provided due to reasonable request. Please contact corresponding author for this purpose(E.mail:[email protected])

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No competing interests reported.

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Psychometric adequacy of the Persian adapted version of the Tilburg Frailty Indicator (P- TFI)

Status:

Journal Publication

Version 1

Abstract

Introduction

Design

Phase 1

Translation

Phase 2

Content and face validity

Phase 3

Reliability

Construct Validity

Predictive validity:

Participations

Data collection

Measures:

TFI- Part B

Other Measures of Frailty

Data analysis

Results

Participant characteristics

Reliability

Construct validity (convergent and divergent validity)

Discussion

Abbreviations

Declarations

References

Additional Declarations

Status:

Journal Publication

Version 1